Vice Chairman Hart

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


Good morning. Welcome to the Boardroom of the National Transportation Safety Board. I am Christopher Hart, and it is my privilege to serve as Acting Chairman of the NTSB. Joining me are my fellow Board Members: Member Robert Sumwalt, Member Mark Rosekind and Member Earl Weener.

We'll begin with some housekeeping. All remarks at this Board meeting will be simultaneously interpreted in Korean and Mandarin and will be broadcast over the provided headsets. Korean will be broadcast on Channel 4, Mandarin on Channel 5, and English on Channel 6. If you are having a problem with your headset, please raise your hand and someone will come to assist you. We will take a few moments to ensure everyone's headset is working before we begin. Please note the nearest exit in the unlikely event of an emergency evacuation alarm. You can use the rear doors where you entered the Conference Center or another set of emergency doors located on the side of the stage in front.

As a courtesy to others, please silence your electronic devices.

I would like to take this opportunity to recognize the excellent work performed by former NTSB Chairman Deborah Hersman and by our investigative team on-scene in San Francisco. Thank you all for your hard work on-scene and throughout the investigation.

Because Asiana Airlines is based in South Korea, we worked closely with our counterparts at the Korean Aviation and Railway Accident Investigation Board, or KARAIB, in the course of this investigation. We welcome Chairman Cho and Mister Park, the KARAIB accredited representative, as well as the other distinguished leaders and staff from KARAIB who are in the audience today. Thank you for your collaboration and continued support.

I also want to thank United Airlines, Asiana's Star Alliance partner, for going above and beyond by assisting families affected by this crash, supporting our investigative team at the crash site, and assisting with wreckage recovery and removal. We were also aided in this process by exemplary cooperation from San Francisco International Airport, the Federal Bureau of Investigation, and the Red Cross.

Today, for the first time, we meet in open session, as required by the Government in the Sunshine Act, to consider the crash of Asiana Airlines Flight 214 on July 6, 2013 – the first fatal commercial airliner crash in the U.S. in almost four and a half years. This meeting is being webcast live, with Mandarin Chinese and Korean translation, to viewers around the world.

Asiana Flight 214, a Boeing 777, struck a seawall on approach to runway 28L at San Francisco International Airport. The tail of the airplane broke off at the aft pressure bulkhead. A post-crash fire began in the right engine and progressed into the fuselage.

One hundred and eighty-seven people suffered injuries, 49 of them serious. And tragically, three young women lost their lives.

On behalf of my fellow Board members and the entire NTSB staff, I offer our condolences to the families and friends of those who were lost, and to those whose lives were forever changed by their injuries. Nothing can replace the loss of your loved ones or undo the trauma of a life-changing injury. But our goal in this investigation is to help prevent similar accidents in the future.

Despite the tragic fatalities and injuries, more than 300 passengers and crew survived this crash, which in years past might have resulted in scores or hundreds of fatalities. Safety advances such as seats that can withstand 16 times the force of gravity, and fire blocking materials, gave the cabin crew the time and the opportunity to evacuate the airplane.

Although four of the cabin crew were ejected from the airplane and two were trapped by slides that inflated inside the cabin, the remaining crew helped passengers evacuate the airplane. Then, with the help of the first officer, they freed the two trapped cabin crew members.

Other passengers were extracted by aircraft rescue and firefighting, or ARFF, personnel – first responders who charged into the smoke-filled wreckage to search for survivors, not knowing whether or when the fire might suddenly intensify.

In the chaos of the crash site, seconds counted. Nevertheless, something happened that never should have: ARFF vehicles rolled over one of the crash victims outside of the burning airplane.

Our accident investigators looked at all of these post-crash aspects of the accident, in an exhaustive investigation that included an investigative hearing last December. The report that the Board considers today includes numerous recommendations on these post-crash events.

The report also answers the basic question about the accident itself:

Why did this airplane crash while executing a visual approach on a clear day?

The Boeing 777 is one of the most sophisticated and automated aircraft in service. Automation has unquestionably made aviation safer and more efficient. But the more complex automation becomes, the more challenging it is to ensure that the pilots adequately understand it.

In this instance, the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway.

More than 15 years ago, Professor James Reason wrote, "In their efforts to compensate for the unreliability of human performance, the designers of automated control systems have unwittingly created opportunities for new error types that can be even more serious than those they were seeking to avoid."

Today we will discuss many recommendations in this report that address how humans interact with automation, in order to help prevent similar accidents in the future.

Managing Director Mayer, will you please introduce the staff.