The National Transportation Safety Board held a public meeting today in Washington, D.C. to present its final findings and probable cause statement regarding the Crash of Asiana Airlines Flight 214, which crashed in San Francisco on July 6, 2013. A copy of the probable cause statement is attached below and an abstract of the final report can be found here.
In short, the NTSB places most of the blame on the fight crew for a general lack of diligence and for grossly mismanaging the approach. Specifically, the NTSB criticized the Asiana 214 flight crew for, among other things: (1) failing to follow Asiana’s communications and coordination procedures during the approach; (2) failing to properly manage the aircraft’s vertical flight profile, which is to say that the plane was rarely on the proper glidepath during the approach; (3) failing to initiate a “go-around” until it was too late; (4) failing to properly monitor the plane’s airspeed and altitude; and (5) an inadequate knowledge of the aircraft’s automated flight control systems. All of these factors led to the plane being low and slow on approach with the autopilot system in a mode that did not provide them with any automated protection.
The NTSB also criticized Boeing for the complexity of its autopilot system and for failing to adequately warn pilots of the potential results of a few of the system’s quirks. For example, when the plane’s autothrottle is in “Flight Change” mode, and the autopilot system is in “Hold” mode, the system offers no low speed protection, which is what happened on Asiana 214, and contributed to the crash. In other mode combinations, the system will automatically add power to gain additional speed and altitude if the plane gets too low and slow.
In all, the NTSB issued thirty factual findings regarding conditions and events leading up to the crash and the response afterwards. It also issued twenty-seven safety recommendations addressed to all involved parties, including, the FAA, Asiana, Boeing, the aircraft rescue and firefighting response team, and the City and County of San Francisco.
The NTSB stated that the following things were not factors in the accident: flight crew certification and qualification, flight crew behavioral or medical conditions, use of drugs or alcohol, airplane certification and maintenance, pre-impact failures of the aircraft, engines or other systems, and the air traffic controllers’ handling of the flight.
Probable Cause Statement