NTSB photo of the debris field from Asiana 214's impact at SFO

America’s NTSB has determined that the fatal crash last July of Asiana Airlines Flight 214, as it was landing at San Francisco,  was caused by the pilots mismanaging the descent and not aborting the landing to try again.

However the safety agency has also criticised the training given to the pilots,  and the pilots’ over reliance on the automated systems on board the 777-200ER, and the complexities of the jet’s autopilot system.

It says, inter alia, that they misused automated systems they didn’t fully understand.

Among other things, the NTSB recommends a certification design review and enhanced training on the Boeing 777 autoflight system.

The findings have caused some surprise, particularly in the US, where the long running debate over the differing emphasis Airbus and Boeing place on automated control systems and flight envelope protection has largely argued that the US approach of less automation and more pilot discretion makes it better.

This was however contradicted by the pilots of the 777 in question, who testified that they were surprised by the failure of the autopilot system on the airliner to work as expected and retrieve the situation as the jet made its final approach too steeply and too slowly, striking the seawall at the end of the runway and being destroyed by the ensuing breaking up of the airframe and a fire in the crash that killed two persons on board and saw a third passenger accidentally killed when run over by a fire truck.

An automation surprise aftermath: Asiana 214's severed main landing gear

There are a number of documents that need to be read to understand and give context to the NTSB’s findings.

It’s full report will not be released for several days, but the NTSB has released this summary.

This report on USA Today gives a balanced review of the NTSB media conference that announced its findings overnight together with responses by Asiana and Boeing.

However for those interested in the piloting and automation issues considered by the NTSB this report by Flightglobal may be the most informative of all.

Earlier this month a Boeing submission to the safety agency which was highly critical of Asiana was released by the NTSB and can be accessed through this Plane Talking report.

This email from Boeing, received early this morning, sets out its full response to the NTSB findings.

•          The victims of this tragedy, their families and loved ones continue to be in our thoughts,
•          Boeing respectfully disagrees with the NTSB’s statement that the 777’s auto-flight system contributed to this accident, a finding that we do not believe is supported by the evidence.
•          We note that the 777 has an extraordinary record of safety – a record established over decades of safe operation.
•          More specifically, 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.
•          As noted in more detail in our submission, the evidence collected during this investigation demonstrates that all of the airplane’s systems performed as designed.    
•          We are committed to a process of continual improvement of our airplanes, and we will carefully review the NTSB’s recommendations.
•          However, it is important that any recommendation concerning changes to the airplane’s design be reviewed with great care, and with due consideration for the potential unintended consequences of any change.

Bret Jensen
BCA Engineering Communications

It would be fair to say that the arguments about the values of automation,  but also its risks and the need for better training to counter automation failures or surprises, has been booted to a higher level by the NTSB.

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