NTSB Findings Fault Asiana Crew for ‘Mismanagement’ in SFO Crash

The National Transportation Safety Board’s much-anticipated report on the ill-fated Asiana Airlines plane that crashed at San Francisco International Airport last year was released on Tuesday, and the NTSB focused its attention on what it considered the crew’s excessive reliance on automated flight controls they did not understand as well as the crew’s mismanagement of the plane’s landing. And San Francisco airplane accident attorney Gregory J. Brod would point out that the NTSB panel findings were fairly specific in determining what went wrong, why and who was largely to blame.

According to the San Francisco Chronicle, the NTSB found that the three-member crew of the Asiana Airlines ultra-modern Boeing 777 that crashed upon landing, broke apart and caught fire at SFO on July 6 did not adequately understand the plane’s systems and “over-relied on automated systems that they did not full understand.” As a result of the crash, the worse ever at SFO, three passengers died and nearly 200 were injured when the plane hit a seawall short of the runway.


Although an SFO glide slope indicator, which guides planes on a 3-degree descent path to the runway, was not functioning at the time of the crash, the NTSB found that not to be a contributing factor to the tragedy. Instead, the NTSB faulted the crew of Asiana Flight 214 for flying the craft at 118 mph when it slammed into the seawall, significantly slower than the recommended speed of 157 mph for a landing. In addition, the crew missed several opportunities to realize that they were losing too much speed as the jet descended below 500 feet. By the time the crew realized what was happening it was too late to abort the landing.

Other contributing factors to the crash, according to the NTSB, were the likelihood that the crew was fatigued at the end of a cross-Pacific journey from South Korea and that they were distracted by cockpit duties during the airplane’s descent into SFO, both of which would have compromised the crew’s ability to recognize that the jet was descending too rapidly and losing speed.

Tellingly, the mistakes committed by the pilots were not due to any incompetence, said NTSB board member Robert Sumwalt, but rather “because of an expectation that the autopilot auto throttle system would do something the airplane was not designed to do.”
Sumwalt went on to say that training for using the automated throttle system of the Boeing 777 was insufficient.

As a result of its findings, the NTSB recommended that Boeing develop better training manuals and procedures for using its automated throttle controls and that Asiana improve its training methods and afford its pilots more manual flight instruction to better equip them to deal with any confusion caused by automation.

Asiana officials have attempted to shift the blame to Boeing for its seemingly vexing automation systems, but the aircraft manufacturer has strongly defended its plane and received some validation from the NTSB.

“This was a seasoned flight crew that misunderstood the flight controls they commanded,” said Christopher Hart, the NTSB’s acting chairman, at the conclusion of the board’s hearing. “We have learned that pilots must understand automation but not become over-reliant upon it. The pilots must always be the boss.”

The NTSB probe concluded that “flight crew mismanagement” was the probable cause of the accident, but also found that there were deficiencies in training, procedure and radio communications among emergency crews that hampered the overall ground response to the crash. One of the three fatalities occurred when a 16-year-old passenger was run over by two responding San Francisco Fire Department fire rigs during the post-crash confusion, an earlier San Mateo County Coroner’s Office report had concluded.

Hopefully, the NTSB’s findings and recommendations will help avoid disasters similar to the one at SFO that shocked the world last July. Unfortunately, though, airplane accidents occur for a variety of reasons, and those people who have been injured or lost loved ones in an aviation accident need to seek legal advice as soon as possible. We urge anyone in such a situation to contact the experienced attorneys at the Brod Law Firm for a free consultation.
-James Ambroff-Tahan contributed to this article.

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