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
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
Many of the recommendations in the NTSB's report address the questions raised
by this mismanagement of the airplaneâ€™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
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
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
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
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
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
We stand adjourned.