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NTSB: Asiana plane crash due to pilot mismanagement


By JOAN LOWY and MARTHA MENDOZA

WASHINGTON (AP) -- Pilot mismanagement and confusion caused Asiana Flight 214 to crash in San Francisco last year, federal accident investigators concluded Tuesday.

The National Transportation Safety Board said there was confusion over whether one of the airliner's key controls was maintaining speed.

The agency also cited the complexity of the Boeing 777's autothrottle and pilot training by the South Korea-based airline as contributing to the crash, which killed three passengers and injured more than 200.

The plane, with 307 people on board, was too low and too slow during the landing attempt. Its tail struck a seawall and was ripped off. The rest of plane went spinning and sliding down the runway. The crash was the only fatal passenger airline accident in the U.S. in the last five years.

Before the vote, Chris Hart, the NTSB's acting chairman, said that increasingly complex automated aircraft controls designed to improve safety are instead creating new opportunities for error.

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

Among the other issues raised by the investigation are some that long have concerned aviation officials, including hesitancy by some pilots to abort a landing when things go awry or to challenge a captain's actions.

The irony of the accident is that it occurred at all. Three experienced pilots were in the cockpit on July 6, 2013. The plane, a Boeing 777, had one of the industry's best safety records. And weather conditions that sunny day were near perfect.

But the wide-bodied jetliner with 307 people on board was too low and too slow during the landing. It struck a seawall just short of the runway, ripping off the tail and sending the rest of the plane spinning and skidding down the runway. When the shattered plane came to rest, a fire erupted.

Despite the violence of the crash, only three people were killed - Chinese teens seated in the back who may not have been wearing their seatbelts and were thrown from the plane. One of the teenage girls survived the crash but was run over by two rescue vehicles in the chaos afterward. Nearly 200 people were injured.

In documents made public by the safety board, Asiana acknowledged the likely cause of the accident was the crew's failure to monitor and maintain the plane's airspeed, and its failure to abort the landing when in trouble. The South Korea-based airline said the pilot and co-pilot reasonably believed the automatic throttle would keep the plane flying fast enough to land safely, when in fact the auto throttle was effectively shut off after the pilot idled it to correct an unexplained climb earlier in the landing.

Asiana said the plane should have been designed so that the auto throttle would maintain the proper speed after the pilot put it in "hold mode."

Boeing had been warned about the problem by U.S. and European aviation regulators. Asiana urged the safety board to recommend that the aircraft maker be required to include an audible warning to alert pilots when the throttle changes to a setting in which it no longer is maintaining speed.

"Asiana has a point," said John Cox, a former airline pilot and aviation safety consultant, "but this is not the first time it has happened. Any of these highly automated airplanes have these conditions that require special training and pilot awareness. ... This is something that has been known for many years and trained for many years."

Boeing told the board there was nothing wrong with the plane, and the crash was caused by the failure of the pilots to maintain speed and to abort the landing when the approach had become unstable, as required by their company's policies. An unstable approach occurs when a plane's speed or rate of descent is too fast or to slow, or the plane isn't properly aligned for landing.

Captain Lee Kang Kuk, 45, a veteran pilot who was new to the 777, was flying the plane. Because an airport navigational aid that helps planes land wasn't working that day, Kuk was flying a visual approach that involves lining up the jet for landing by looking through the windshield and using numerous other cues, rather than relying on a radio-based system called a glide-slope that guides aircraft to the runway. A training captain was sitting next to him in the right seat watching his performance.

Kuk told transportation accident investigators that he did not immediately move to abort the landing after it became unstable because he felt only the instructor pilot had that authority. Cockpit culture in which the senior captain is viewed as supreme was identified as a factor in several South Korean airliner crashes in the 1980s and `90s. Afterward, procedures and hierarchies were overhauled in Korea and elsewhere, including the U.S.

NTSB Blames Pilots, Automated Systems For Asiana Crash


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bronbronco27 June 24 2014 at 2:44 PM

It always is a good idea to check the pilot manifest before flying - I would never have gotten on that plane with the names the news reported, good lord. Sum Ting Wong, Wi Tu Lo, Ho Lee ****, and Bang Ding Ow is a clear OMEN!

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7 replies
abudotcom June 24 2014 at 3:03 PM

This new comment format is lousy….

Flag Reply +12 rate up
3 replies
rebesal June 24 2014 at 3:36 PM

FLY the plane...FLY THE PLANE! Don't let it fly you, and for the guy in the right seat--Don't just sit there and let the Captain dig himself a HOLE! Say something, or DO something! Cripes, this is SO DARN BASIC! None of these clowns deserved to be in the cockpit.

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wtrfrd June 24 2014 at 3:38 PM

100% Pilot error. The two principle causes of dangerous / deadly landings are flight instruction 101. Coming in "Hot and High" or coming in "Slow and Low" . Too much flight speed and too much altitude and you will not have enough runway. Solution... full throttle go around... add throttle bring up flaps. Too low and slow... throttle up. You will notice throttling up and down in most landings. Not so much with veteran pilots who can grease those babies right on the numbers. Pilot error and cultural tradition to never challenge a superior.Add a comment...

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Kate June 24 2014 at 2:34 PM

Both pilots were certainly at fault, but I think it is a valid point that there should be an automatic alert if a plane is not traveling at sufficient speed or height to safely land. Then neither pilot would have hesitated to abort the landing. The plane itself would have told them it couldn't.

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2 replies
k9minds4recovery Kate June 24 2014 at 3:07 PM

South Korea wants all aircraft to be made IDIOT Proof so its pilots can fly them

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slackwarerobert Kate June 24 2014 at 5:04 PM

How do you warn about a height, when the purpose of landing is a height of ZERO, and a SPEED of ZERO. The plane was the one flying. BOTH pilots said so. If you DON

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1 reply
Chris slackwarerobert June 24 2014 at 8:52 PM

Because the ILS approach has a course and glidepath information being sent to the aircraft . It registers as high, low, left or right and airspeed is measured as too slow by the angle of attack. It is quite easy to warn and it works quite well.

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stephen284 June 24 2014 at 3:12 PM

Base on the comments it's clear that a bunch of Microsoft Pilots are still at their keyboards:

1) The plane has an audible stall warning.

2) The plane calls out height from ground level on approach.

3) The Pilot in Command (PIC) took the plane off "Auto-Throttle," and therefore was responsible for throttle management.

4) Visual landings are not uncommmon.

5) When a flight system is not performing as expected, a pilot MAY turn it off.

6) I've flown airplanes; they don't land themselves.

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2 replies
wtrfrd stephen284 June 24 2014 at 3:50 PM

Great points. Greatn post. My first flight instructor in private single engines ( Cesna 150 ) explained that "we tie down airplanes here because they want to do what they are designed to do...fly. The trick is to know how to stop them from flying in a controlled manner." First landing instructions were too 'hot and high' and too 'low and slow'. As a rookie he would make me touch each instrument as I scanned them. WW II vet and great teacher... UNFORGIVING of any error in a procedure he had taght me.

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slackwarerobert stephen284 June 24 2014 at 5:12 PM

Now who is using windows flight sim.
ALL planes will land themselves, the entire flight is KEEPING it from happening till you want it to. Gravity will land any plane, it may not be a pretty landing you walk away from, but the plane WILL be on the ground.

The problem WAS the automated controls, and the morons at the airport and FTA want to mandate MORE automation, when the obvious solution is to BAN automation.

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onionson June 24 2014 at 2:31 PM

I'm not buying pilot error. Like the article says, auto throttle is a complicated device and these planes are supposed to practically land themselves. Trying to react to an automating landing feature that malfunctions at the last second is a more likely scenario.

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11 replies
realrambo June 24 2014 at 2:30 PM

I agree it may have been a pilot miss management , but the fact they were landing that jumbo jet by looking out of the window like the old plane in the 1930 is a hell of a contribution this aside pilot should have an audible warning reminding them of their speed , no where it is said it was turned off , Boeing and all manufacturer are quick to blame the pilot when they all can be part of the solution . It could have been any airline .

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2 replies
philips0811 realrambo June 24 2014 at 2:47 PM

Yes, all those times the 777 has landed safely (IE, every single other time) were just blind luck.

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tom841 realrambo June 24 2014 at 3:58 PM

One of the first things a pilot is taught to do is crosscheck the instruments in the cockpit. One of those instruments is the airspeed indicator. If the speed is too slow, the pilot should take corrective action. Another early skill taught to pilots is executing a visual approach. It's not like the cockpit crew found out half way through the approach he ILS was out of order; they knew it was a visual approach well before they initiated it. The NTSB nailed this one.

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1 reply
slackwarerobert tom841 June 24 2014 at 5:01 PM

Then why are they blaming the plane crash on the deaths when it was the AIRPORT firetrucks that killed them?

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ladmer June 24 2014 at 2:41 PM

You would think that in such a sophisticated aircraft the crew would have the cockpit management training to go with it?!

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eulerckt June 24 2014 at 2:32 PM

This may fly in the faces of current MBA employment philosophy. Some jobs require adequate experience....You can't read the flight manual, no matter how well written, alone and successfully fly an aircraft. This is also a case in point relative to 'autonomous' automobiles.

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1 reply
slackwarerobert eulerckt June 24 2014 at 5:08 PM

Speak for yourself. Give me the stall speed, and the glide angle, I will put it down on the pavement. It isn't rocket science. Which IS useful for building V-2's., and mach1+ drones. These planes are built so an idiot can fly them. To date only TWO have managed to fly the Write Brothers plane design. And both those pilots lived to tell about it.

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