NTSB: Asiana Pilots Mismanaged Landing

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The Asiana Airlines flight crew mismanaged the descent of a 777 into San Francisco International Airport last July, causing a fiery crash that killed three passengers and seriously injured 49, the NTSB said in its probable-cause hearing on Tuesday. The pilots made several mistakes and delayed the execution of a go-around after they became aware that the airplane was below the acceptable glide path, the board said. Contributing to the accident were "the complexities of the auto-throttle and autopilot flight director systems," which the board said were inadequately described in Boeing's documentation and in Asiana pilot training. Other contributing factors were inadequate crew training and crew fatigue. The board also said emergency responders on the scene, who ran over one of the crash victims with a fire truck, should have been better trained and equipped.

The board followed up with 27 safety recommendations, to the airline, Boeing, the aircraft firefighting group, and the city and county of San Francisco. Acting Chairman Christopher Hart said the board's investigation found the answer to the basic question about the accident: Why did this airplane crash while executing a visual approach on a clear day? "The flight crew over-relied on automated systems that they did not fully understand," Hart said, in his opening remarks. "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.'" The board meeting presentations are posted online, and a video of the meeting will be added to the NTSB archive. A synopsis of the board's report has been posted online; the full report will be posted in a few weeks.