WASHINGTON -- As Asiana Airlines Flight 214 descended to its doom in the final minutes of its approach to San Francisco International Airport, its crew had several chances to avert disaster.

But a tragic combination of the pilots' poor judgment, their unfamiliarity with the complex gear in the high-tech airliner and emergency responders who lacked training and proper communications equipment all contributed to the fiery crash and deaths of three people, federal investigators concluded Tuesday, nearly one year after the catastrophe.

While the conclusions produced no major surprises, they added more detail to what had been previously known about the crash.

Fire crews put out fire of Asiana Airlines Boeing 777 that crashed while landing at San Francisco International Airport on Saturday, July 6, 2013. (John
Fire crews put out fire of Asiana Airlines Boeing 777 that crashed while landing at San Francisco International Airport on Saturday, July 6, 2013. (John Green/Bay Area News Group) ( JOHN GREEN )

Beginning 14 miles from the airport, "there were what we call maybe cascading errors," said Roger Cox, an investigator for the National Transportation Safety Board during a long-awaited hearing into the cause of the July 6 disaster. "Early errors are fairly common and easy to recover from." But, he added, the errors "compounded and became more egregious."

The biggest problem was the flight crew. They "over-relied on systems they did not understand and flew the aircraft too low and slow, colliding with a sea wall at the end of the runway," said Christopher Hart, the agency's acting director.


Advertisement

Moments before that, the crew still had a chance to avert disaster by aborting the landing and rerouting the plane around the airport for a safer landing approach. But crew members failed to notice that the automatic controls had idled the plane's engines and that they were dangerously losing altitude, the safety board said, because they were fatigued and hamstrung by "role confusion" over who had authority to make critical flight decisions. The veteran pilot was learning to fly the Boeing 777 and had an instructor pilot sitting next to him.

Moreover, the agency said Asiana's policy of not encouraging pilots to fly planes manually during training may have limited the ability of Flight 214's pilot to take "appropriate corrective action."

San Francisco's emergency personnel also were criticized.

While praising firefighters for rescuing several passengers from the burning wreckage and having more than the required number of personnel on hand, the report said "the arriving incident commander placed an officer in charge of the fire attack" who hadn't been properly trained. The responders also had communication problems, including being unable "to speak directly with units from the airport on a common radio frequency" and didn't rush medical buses to the scene, which "delayed the arrival of backboards to treat seriously injured passengers."

National Transportation Safety Board investigators work Sunday, July 7, 2013, on their investigation into the cause of Saturday’s crash of Asiana
National Transportation Safety Board investigators work Sunday, July 7, 2013, on their investigation into the cause of Saturday's crash of Asiana Flight 214, a Boeing 777 aircraft, at San Francisco International Airport. Two people were killed and close to 200 injured in the crash. (NTSB) ( NTSB )

In addition, the report said airport emergency officials in general lack policies "for ensuring the safety of passengers and crew at risk of being struck or rolled over by a vehicle" during rescue operations. During the chaotic initial response to the Asiana crash, two firetrucks ran over one of the teenage passengers lying outside the plane. The San Mateo County coroner ruled the girl was alive when she was hit, but the San Francisco Fire Department disputes that finding.

Still more criticism was reserved for Boeing, which made the plane.

Because of the aircraft's complexities and Boeing's inadequate description of those issues, the report said, "the pilot flying had an inaccurate understanding" of some of its technology, "which led to his inadvertent deactivation of automatic airspeed controls." As a result, the federal agency urged Boeing to consider modifying its flight control system to alleviate the problem and to revise the plane's operating manual to help pilots better understand the equipment.

The safety board also noted that two of the three passengers who were killed weren't wearing their seat belts when they were ejected from the crashed plane. Both passengers, including the one run over by the firetrucks, "would likely have remained in the cabin and survived if they had been wearing them," the report said.

Boeing, which previously denied responsibility for the crash, took issue with the conclusion that its equipment's complexity might have played a role in the accident.

"The auto-flight system has been used successfully for over 200 million flight hours across several airplane models and for more than 55 million safe landings," Boeing said in a statement, adding that "the evidence collected during this investigation demonstrates that all of the airplane's systems performed as designed."

While acknowledging that its crew failed to fly the plane properly, Asiana also has maintained that Boeing's complex equipment contributed to the accident. After the safety board's hearing, the airline issued a separate statement saying the recommendation regarding Boeing "can help ensure such an incident does not happen again."

Asiana added that it has bolstered its flight crew training and hired an outside expert to help improve its safety since the accident.

Officials with San Francisco International Airport and the San Francisco Fire Department also issued statements, saying they have beefed up emergency personnel training and made other safety improvements following the fatal mishap.

As part of its report, the safety board issued recommendations to Asiana, Boeing, San Francisco officials and the Federal Aviation Administration to help prevent a similar accident in the future. Although the agency's findings are not admissible in court, it says that more than 82 percent of its past recommendations have been adopted "by those in a position to effect change."

Contact Steve Johnson at sjohnson@mercurynews.com or 408-920-5043. Follow him at Twitter.com/steveatmercnews.

NTSB recommendations
The National Transportation Safety Board's recommendations following the Asiana Flight 214 crash include:
Asiana should bolster crew training about automatic flight-control equipment and improve pilot proficiency by making sure their training includes more manual operation of planes instead of just relying on automatic controls.
Boeing should consider modifying its complicated flight control systems.
San Francisco's emergency officials should fix the communication problems experienced during the Asiana crash and make sure all of the Fire Department's firefighting and medical equipment is used in future disaster drills.
The safety board's own Aircraft Rescue and Firefighting Working Group should work with experts to recommend "best practices to avoid striking or rolling over" casualties of airplane crashes.