NTSB Press Release Asiana 214

[A Life Aloft]

NTSB Finds Mismanagement of Approach and Inadequate Monitoring of Airspeed Led to Crash of Asiana flight 214
Multiple contributing factors also identified

June 24


WASHINGTON - In a Board meeting held today, the National Transportation Safety Board determined that Asiana flight 214 crashed when the airplane descended below the visual glidepath due to the flight crew's mismanagement of the approach and inadequate monitoring of airspeed. The Board also found that the complexities of the autothrottle and autopilot flight director systems, and the crew's misunderstanding of those systems, contributed to the accident.

On July 6, 2013, about 11:28 a.m. (PDT), the Boeing 777 was on approach to runway 28L at San Francisco International Airport in San Francisco, California 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.

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

As a result of this accident investigation, the NTSB made recommendations to the Federal Aviation Administration, Asiana Airlines, The Boeing Company, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco.

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.

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

A synopsis of the NTSB report, including the probable cause, findings, and a complete list of the 27 safety recommendations, is available at http://www.ntsb.gov/news/events/2014/asiana214/abstract.html. The full report will be available on the website in several weeks.

Office of Public Affairs
490 L'Enfant Plaza, SW
Washington, DC 20594
Keith Holloway
(202) 314-6100
keith.holloway@ntsb.gov

 

[A Life Aloft]

FINDINGS

1. The following were not factors in the accident: flight crew certification and qualification; flight crew behavioral or medical conditions or the use of alcohol or drugs; airplane certification and maintenance; preimpact structural, engine, or system failures; or the air traffic controllers’ handling of the flight.
2. Although the instrument landing system glideslope was out of service, the lack of a glideslope should not have precluded the pilots’ successful completion of a visual approach.
3. The flight crew mismanaged the airplane’s vertical profile during the initial approach, which resulted in the airplane being well above the desired glidepath when it reached the 5 nautical mile point, and this increased the difficulty of achieving a stabilized approach.
4. The flight crew’s mismanagement of the airplane’s vertical profile during the initial approach led to a period of increased workload that reduced the pilot monitoring’s awareness of the pilot flying’s actions around the time of the unintended deactivation of automatic airspeed control.
5. About 200 ft, one or more flight crewmembers became aware of the low airspeed and low path conditions, but the flight crew did not initiate a go-around until the airplane was below 100 ft, at which point the airplane did not have the performance capability to accomplish a go-around.
6. The flight crew was experiencing fatigue, which likely degraded their performance during the approach.
7. Nonstandard communication and coordination between the pilot flying and the pilot monitoring when making selections on the mode control panel to control the autopilot flight director system (AFDS) and autothrottle (A/T) likely resulted, at least in part, from role confusion and subsequently degraded their awareness of AFDS and A/T modes.
8. Insufficient flight crew monitoring of airspeed indications during the approach likely resulted from expectancy, increased workload, fatigue, and automation reliance.
9. The delayed initiation of a go-around by the pilot flying and the pilot monitoring after they became aware of the airplane’s low path and airspeed likely resulted from a combination of surprise, nonstandard communication, and role confusion.
10. As a result of complexities in the 777 AFCS and inadequacies in related training and documentation, the pilot flying had an inaccurate understanding of how the autopilot flight director system and autothrottle interacted to control airspeed, which led to his inadvertent deactivation of automatic airspeed control.
11. If the autothrottle automatic engagement function (wakeup), or a system with similar functionality, had been available during the final approach, it would likely have activated and increased power about 20 seconds before impact, which may have prevented the accident.
12. A review of the design of the 777 automatic flight control system, with special attention given to the issues identified in this accident investigation and the issues identified by the Federal Aviation Administration and European Aviation Safety Agency during the 787 certification program, could yield insights about how to improve the intuitiveness of the 777 and 787 flight crew interfaces as well as those incorporated into future designs.
13. If the pilot monitoring had supervised a trainee pilot in operational service during his instructor training, he would likely have been better prepared to promptly intervene when needed to ensure effective management of the airplane’s flightpath.
14. If Asiana Airlines had not allowed an informal practice of keeping the pilot monitoring’s (PM) flight director (F/D) on during a visual approach, the PM would likely have switched off both F/Ds, which would have corrected the unintended deactivation of automatic airspeed control.
15. By encouraging flight crews to manually fly the airplane before the last 1,000 ft of the approach, Asiana Airlines would improve its pilots’ abilities to cope with maneuvering changes commonly experienced at major airports and would allow them to be more proficient in establishing stabilized approaches under demanding conditions; in this accident, the pilot flying may have better used pitch trim, recognized that the airspeed was decaying, and taken the appropriate corrective action of adding power.
16. A context-dependent low energy alert would help pilots successfully recover from unexpected low-energy situations like the situation encountered by the accident pilots.
17. The flight attendants acted appropriately when they initiated an emergency evacuation upon determining there was a fire outside door 2R. Further, the delay of about 90 seconds in initiating an evacuation was likely due partly to the pilot monitoring’s command not to begin an immediate evacuation, as well as disorientation and confusion.
18. Passengers 41B and 41E were unrestrained for landing and ejected through the ruptured tail of the airplane at different times during the impact sequence. It is likely that these passengers would have remained in the cabin and survived if they had been wearing their seatbelts.
19. Passenger 42A was likely restrained for landing, and the severity of her injuries was likely due to being struck by door 4L when it separated during the airplane’s final impact.
20. The dynamics of the impact sequence in this accident were such that occupants were thrown forward and experienced a significant lateral force to the left, which resulted in serious passenger injuries that included numerous left-sided rib fractures and one left-sided head injury.
21. The reasons for the high number of serious injuries to the high thoracic spine in this accident are poorly understood.
22. The release and inflation of the 1R and 2R slide/rafts inside the airplane cabin was a result of the catastrophic nature of the crash, which produced loads far exceeding design certification limits.
23. Clearer guidance is needed to resolve the concern among airport fire departments and individual firefighters that the potential risk of injuring airplane occupants while piercing aircraft structure with a skin-penetrating nozzle outweighs the potential benefit of an early and aggressive interior attack using this tool.
24. Medical buses were not effectively integrated into San Francisco International Airport’s monthly preparation drills, which played a part in their lack of use in the initial response to the accident and delayed the arrival of backboards to treat seriously injured passengers.
25. Guidance on task prioritization for responding ARFF personnel, that addresses the presence of seriously injured or deceased persons in the immediate vicinity of an accident airplane, is needed to minimize the risk of these persons being struck or rolled over by vehicles during emergency response operations.
26. The overall triage process in this mass casualty incident was effective with the exception of the failure of responders to verify their visual assessments of the condition of passenger 41E.
27. The San Francisco Fire Department’s aircraft rescue and firefighting staffing level was instrumental in the department’s ability to conduct a successful interior fire attack and successfully rescue five passengers who were unable to self-evacuate amid rapidly deteriorating cabin conditions.
28. Although no additional injuries or loss of life were attributed to the fire attack supervisor’s lack of aircraft rescue and firefighting (ARFF) knowledge and training, the decisions and assumptions he made demonstrate the potential strategic and tactical challenges associated with having non-ARFF trained personnel in positions of command at an airplane accident.
29. Although some of the communications difficulties encountered during the emergency response, including the lack of radio interoperability, have been remedied, others, such as the breakdown in communications between the airport and city dispatch centers, should be addressed.
30. The Alert 3 section of the San Francisco International Airport’s emergency procedures manual was not sufficiently robust to anticipate and prevent the problems that occurred in the accident response.

PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.

 

[greg1016]

The article in the Washington Post also links a youtube video of a computer reconstruction of cockpit events:

http://www.washingtonpost.com/news/...ing-on-systems-they-didnt-understand/?hpid=z4

 

[francis03]

I just noticed in the video the amount of times the Pilot Monitoring referred to the Pilot Flying as "sir."

Even if the dude beside me is considered a Skygod, when I notice that we're gonna eat it and he's not doing anything, I would take over. "Bro, we're about to die. My controls, Full Power, TOGA Set." Granted I only fly DA40s..

 

[Nark]

I just noticed in the video the amount of times the Pilot Monitoring referred to the Pilot Flying as "sir."

Even if the dude beside me is considered a Skygod, when I notice that we're gonna eat it and he's not doing anything, I would take over. "Bro, we're about to die. My controls, Full Power, TOGA Set." Granted I only fly DA40s..

Cultural differences, crew environment etc...

 

[dustoff17]

Cultural differences, crew environment etc...

EXACTLY!! Even in a DA40, in THAT culture, you, too, would say, "Sir"!

 

[francis03]

That sort of culture does not belong in the cockpit, especially of an airliner. I grew up in that part of the world and I'm very familiar with that culture.

A couple of years back in my country, an A320 overshot a 6400 ft. runway because it came in too hot and high and touched down with insufficient runway remaining. The FO (who was pilot monitoring) didn't challenge the captain at any point since, rumor has it, that "sir" in the left seat was the one who cleared him to line flying.

 

[ChasenSFO]

I'll be looking forward to the full report. First I've heard about the 2 actual crash fatalities. Always keep the damn seat-belt on, always.

Cultural differences, crew environment etc...

True, but we all know that compromises safety and just won't cut it. It's a human factor that has lead to several fatal accidents and numerous incidents over the years that were otherwise entirely preventable.

 

[Deleted member 27505]

NTSB Finds Mismanagement of Approach and Inadequate Monitoring of Airspeed Led to Crash of Asiana flight 214
Multiple contributing factors also identified

June 24


WASHINGTON - In a Board meeting held today, the National Transportation Safety Board determined that Asiana flight 214 crashed when the airplane descended below the visual glidepath due to the flight crew's mismanagement of the approach and inadequate monitoring of airspeed. The Board also found that the complexities of the autothrottle and autopilot flight director systems, and the crew's misunderstanding of those systems, contributed to the accident.

On July 6, 2013, about 11:28 a.m. (PDT), the Boeing 777 was on approach to runway 28L at San Francisco International Airport in San Francisco, California 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.

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

As a result of this accident investigation, the NTSB made recommendations to the Federal Aviation Administration, Asiana Airlines, The Boeing Company, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco.

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.

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

A synopsis of the NTSB report, including the probable cause, findings, and a complete list of the 27 safety recommendations, is available at http://www.ntsb.gov/news/events/2014/asiana214/abstract.html. The full report will be available on the website in several weeks.

Office of Public Affairs
490 L'Enfant Plaza, SW
Washington, DC 20594
Keith Holloway
(202) 314-6100
keith.holloway@ntsb.gov

Dammit! When are we going to get more automation in the cockpit to prevent automation related accidents like this?

 

[ClearedForOption]

Here's the video: (without having to click on any links)

Not as hard to watch as the Colgan video, but hard nonetheless as you can see all the holes in the swiss cheese that they could have plugged with some basic airmanship.

 

[Bandit_Driver]

Dammit! When are we going to get more automation in the cockpit to prevent automation related accidents like this?

we need automation to monitor the automation

 

[Roger Roger]

we need automation to monitor the automation

I know, we could put a person in the cockpit whose primary job is to monitor the outside world, the instruments, and the automation, and ensure that the airplane doesn't get way below both Vref and glideslope.

 

[PositionAndHold]

So the PF gets high. They reset the preselct to 3k, which is SOP every place I've worked once you've descended below the GA altitude. Some how, the PF decides to use flight level change mode on short final? It of course tries to go to the last selected altitude. He then clicks off the AP and manipulates the thrust levers. At that point, once I touch the controls, in my mind I'm hand flying and am responsible for the energy state of the airplane. What. The. Deuce.

 

[Cptnchia]

Once they started the climb to 3000, that's where they should have discontinued the approach. At that point they were all FUBARED. Best to go around and try again.

 

[TrustMeI'maPilot]

I've never understood trying to fly a visual approach with the autopilot on (without an ILS). To me it's much more work to use a vertical AP mode while looking outside than it is to just click it off and do some pilot stuff. Seen guys do it here in the US too.

 

[Baronman]

So what exactly does this " Hold" mode do? Seems like the autothrottles were on, he disconnects the autopilot and holds the thrust levers back and then the AT are in this seemingly useless mode... Are they on? Are they off?

 

[tonyw]

I'm just going to leave this right here....

http://thesilvertelegram.com/wp-content/uploads/2013/07/ktvu-reports-asiana-air-pilots-were-sum-ting-wong-and-ho-lee-•-2013-07-12-16-04-51png-34f5d3d7e99ae99e.png

 

[mshunter]

So yeah, they totally botched this approach, and were/are trying to blame Boeing, EVEN THOUGH the airplane told them what it was doing. What happens if the AP is deferred? Do these guys just not go fly? If you disconnect the AP, even if the thing has auto throttles, WATCH WHAT THE AIRPLANE IS DOING! These guys need to watch "Children of the Magenta."

 

[Baronman]

So yeah, they totally botched this approach, and were/are trying to blame Boeing, EVEN THOUGH the airplane told them what it was doing. What happens if the AP is deferred? Do these guys just not go fly? If you disconnect the AP, even if the thing has auto throttles, WATCH WHAT THE AIRPLANE IS DOING! These guys need to watch "Children of the Magenta."

I doubt they take a 777 across the Pacific frequently (ever) with all APs deferred.

 

[mshunter]

I doubt they take a 777 across the Pacific frequently (ever) with all APs deferred.

And your point? You obviously completely missed mine. It's basic airmanship. You watch your descent, watch your airspeed, and make MANUAL changes when the automation doesn't match the intended input. Which is what these guys did, but failed to monitor one of the most basic things that makes an airplane fly, airspeed. This approach was botched from more than 5 miles out, and they failed to fix it, FROM 5 MILES OUT!

Basic airmanship was lacking here. Maybe they had it at one point in their careers, but they had obviously lost it by this point.