By Steve Johnson and Pete Carey, San Jose Mercury News

WASHINGTON — The deadly crash of Asiana Airlines Flight 214 at San Francisco International Airport directly resulted from the crew’s confusion over the plane’s technology, federal officials said Tuesday, adding that emergency officials responding to the scene were hampered by communication problems and lack of training.

The flight crew “over relied on systems they did not understand and flew the aircraft too low and slow, colliding with a seawall at the end of the runway,” said Christopher Hart, acting director of the National Transportation Safety Board, during a long-awaited hearing into the cause of the July 6 catastrophe, which killed three teenage passengers and injured 187 others. He added that the agency Tuesday will issue a report making recommendations “that address how humans interact with automation to prevent similar accidents in the future.”

Moreover, the agency’s staff said the flight crew “was likely experiencing fatigue,” and the fact that the person flying the plane and the other pilot monitoring him were both captains “led to confusion about who was responsible” for deciding to abort the landing and reposition the airplane for safer approach.

Officials with the safety board also were critical of San Francisco fire officials at the accident scene, saying some of their “operational decision-making reflected a lack of knowledge and training.”

The commander overseeing the emergency responders “was given erroneous information about the lack of fire at the accident site” and emergency personnel couldn’t speak to each other due to glitches with their communications equipment, they said. In addition, the safety board staff faulted fire officials whose trucks twice ran over a teenage passenger, who had been thrown from the crashed plane and died.

The firefighters had “a short window of opportunity” to assess the scene and avoid the girl after they arrived, “but they did not do so.”
With 12 crew members and 291 passengers — including 70 Chinese students and teachers headed to a summer camp — Flight 214 was inbound to San Francisco on a clear day from Seoul, South Korea, with an experienced pilot being trained to fly the 777, and his instructor sitting next to him. As the aircraft passed over the San Mateo Bridge, about 5 miles from the runway, the pilot executed a series of commands that caused it to lose speed rapidly, a problem the pilot discovered too late to execute a go-around for another try at landing.
What caused the confusion in the cockpit has been a key issue of concern, with much of the focus on the technology that has been added to airlines in recent decades to assist pilots.

Asiana has said the accident probably was caused by its flight crew’s failure to monitor and maintain safe airspeed during the landing and that a contributing factor was the crew’s “failure to execute a timely go-around” as required by company procedures. But the airline also faulted the Boeing 777’s complex automation controls for contributing to the accident, claiming “inconsistencies in the aircraft’s automation logic” led the crew to believe that the airplane was maintaining a safe airspeed. It added that warnings from the aircraft that something was wrong were “inadequate.”

Boeing countered in its own filing with the board that the accident would have been avoided “had the flight crew followed procedures and initiated a timely go-around” as the approach became increasingly unstable.

The NTSB can only make recommendations to regulatory agencies such as the Federal Aviation Administration and its probable-cause findings are not admissible in court. However, the agency says that more than 82 percent of its recommendations have been adopted “by those in a position to effect change.”

AFP Photo / Josh Edelson

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