The US National Transportation Safety Board (NTSB) has blamed mismanagement of initial approach by the flight crew and inadequate monitoring of airspeed for causing the crash-landing of Asiana Airlines’ Boeing 777 at San Francisco International Airport last year.
The incident involving Asiana Airlines Flight OZ 214 killed two passengers and left more than 180 injured from the 307 on-board, comprising 291 passengers and 16 crew.
NTSB said that the complexities of the autothrottle and autopilot flight director systems and the crew’s misunderstanding of those systems led to the accident.
It determined that the captain selected an inappropriate autopilot mode as the aircraft was well above the desired glidepath as it neared the runway, a move which resulted in the autothrottle no longer controlling airspeed.
The crew did not notice the decreasing airspeed as the aircraft descended below the desired glidepath and began a go-around manoeuvre when it was below 100ft; however, it was too late and it collided with the seawall, the NTSB said.
NTSB acting chairman Christopher Hart said: "In this accident, the flight crew over-relied on automated systems without fully understanding how they interacted.
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By GlobalData"Automation has made aviation safer. But even in highly automated aircraft, the human must be the boss."
In the wake of this incident, the NTSB has recommended measures to the Federal Aviation Administration (FAA), Asiana Airlines, Boeing, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco.
The recommendations tackle safety issues identified in the investigation, including the need for increased adherence to Asiana flight crew standard operating procedures, more opportunities for manual flying for Asiana pilots, a low energy alerting system, and certification design review and enhanced training on the Boeing 777 autoflight system.
Recommendations also outlined the importance of improved emergency communications, and staffing requirements and training for aircraft rescue and firefighting personnel.
