In a Board meeting held today, the National Transportation Safety Board
determined that Asiana flight 214 crashed when the airplane descended below the
visual glidepath due to the flight crew's mismanagement of the approach and
inadequate monitoring of airspeed. The Board also found that the complexities of
the autothrottle and autopilot flight director systems, and the crew's
misunderstanding of those systems, contributed to the accident.
On July 6, 2013, about 11:28 a.m. (PDT), the Boeing 777 was on approach to
runway 28L at San Francisco International Airport in San Francisco, California
when it struck the seawall at the end of the runway. Three of the 291 passengers
died; 40 passengers, eight of the 12 flight attendants, and one of the four
flight crewmembers received serious injuries. The other 248 passengers, four
flight attendants, and three flight crewmembers received minor injuries or were
not injured. The impact forces and a postcrash fire destroyed the airplane.
The NTSB determined that the flight crew mismanaged the initial approach and
that the airplane was well above the desired glidepath as it neared the runway.
In response to the excessive altitude, the captain selected an inappropriate
autopilot mode and took other actions that, unbeknownst to him, resulted in the
autothrottle no longer controlling airspeed.
As the airplane descended below the desired glidepath, the crew did not
notice the decreasing airspeed nor did they respond to the unstable approach.
The flight crew began a go-around maneuver when the airplane was below 100 feet,
but it was too late and the airplane struck the seawall.
"In this accident, the flight crew over-relied on automated systems without
fully understanding how they interacted," said NTSB Acting Chairman Christopher
A. Hart. "Automation has made aviation safer. But even in highly automated
aircraft, the human must be the boss."
As a result of this accident investigation, the NTSB made recommendations to
the Federal Aviation Administration, Asiana Airlines, The Boeing Company, the
Aircraft Rescue and Firefighting Working Group, and the City of San
These recommendations address the safety issues identified in the
investigation, including the need for reinforced adherence to Asiana flight crew
standard operating procedures, more opportunities for manual flying for Asiana
pilots, a context-dependent low energy alerting system, and both certification
design review and enhanced training on the Boeing 777 autoflight system.
The recommendations also address the need for improved emergency
communications, and staffing requirements and training for aircraft rescue and
"Today, good piloting includes being on the lookout for surprises in how the
automation works, and taking control when needed," Hart said. "Good design means
not only maximizing reliability, but also minimizing surprises and