Vice Chairman Hart

Acting Chairman Christopher A. Hart
Closing Statement
Crash of Asiana Airlines Flight 214
San Francisco, California
July 6, 2013
Washington, DC — June 24, 2014


In closing, I want to recognize the NTSB staff for their hard work in developing and presenting this excellent safety report. Investigator-in-Charge Bill English and his team did a thorough job comprehensively addressing some very complex issues. I also want to thank my fellow Board Members for their very helpful participation in the process.

In this investigation we have learned that pilots must understand and command automation, and not become over-reliant on it. The pilot must always be the boss.

This was a seasoned flight crew with a good safety record. Yet they misunderstood the relationships of the automated systems they commanded. They also failed to work together adequately to monitor and respond to their deteriorating situation.

Many of the recommendations in the NTSB's report address the questions raised by this mismanagement of the airplaneā€™s descent.

We have made recommendations to improve the interface between crew members and automation, both in existing aircraft and in future designs.

We have made recommendations to improve training of flight crew members on these systems.

We have made recommendations to address the complexity of the automation.

We have made recommendations to ensure that pilots have more manual flight proficiency and are less reliant on automation.

In addition to recommendations to reduce the likelihood of crashes, we are also seeking to further improve survivability. For example, we have recommended further study of occupant protection based on the injuries that occurred in this crash.

And, we have made recommendations with the aim of improving the triage process and avoiding vehicle strikes in the course of emergency response.

Crashes like this one are rarer today than ever before, and more survivable, because the industry has made significant safety improvements over the last 20 years. Nevertheless, there is always room for improvement. Continuing that improvement will take considerable effort, but it is an effort that must be made. As many safety experts have said, safety is not a destination but a continuing journey.

Finally, the traveling public should know that when the unexpected happens and airplanes do crash, most crashes are survivable. The trained cabin crew on Asiana flight 214 performed admirably and heroically in this accident. As we board our next flight, all of us should recognize that they are our first line of defense. The first responders also played a crucial role, including by entering a burning airplane to save several lives, and we should never lose sight of the difficulties they encounter in performing their life-saving duties.

Passengers play a key role in their own safety. We implore passengers to take the necessary steps for their own safety. Pay attention to your cabin crew's instructions. Make sure you are buckled in. Adding your efforts to those of regulators and industry can further improve the overall safety of your flight.

We stand adjourned.