An investigation by the National Transportation Safety Board has concluded that inexperienced pilots using automatic flying systems were at the heart of the Asiana plane crash at SFO that killed three passengers and seriously injured 49. It also sheds light on an inadequate emergency response by firefighters at SFO during which two emergency response vehicles ran over passenger Ye Meng Yuan, killing her on the runway. (For a lot more on the Fire Department's flawed response to the crash, see Lauren Smiley's story from this month's magazine, "Dead Right There.")
Acting NTSB chair Christopher Hart said in his opening remarks that the crash had the potential to have been much worse: "Despite the tragic fatalities and injuries, more than 300 passengers and crew survived this crash, which in years past might have resulted in scores or hundreds of fatalities." He also said that the investigation had provided an answer to the one of the central questions surrounding the incident: How a plane on a routine landing could have crashed on a clear day. The investigation has concluded that "the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway."
Contributing to the accident was a lack of experience on the part of the pilots. According to the investigation, the pilot at the flying controls during the landing had logged only 33 hours on the type of plane being flown and the monitoring pilot, charged with instructing the flying pilot, was a "new instructor" on the B777, raising issues of "flight instructor operating experience proficiency."
That lack of experience may have led to the flying pilot's over-reliance on automated controls, which in this case mistakenly "began [to] climb" during the final approach to the runway, after the second pilot set the plane's flaps too late. Although the flying pilot, "counteracted the commanded climb," the plane was not stable enough to make an approach (it was at this point that he reporting being "stressed") and the plane collided with the seawall.
The report blames both the pilots for "lacking critical flying skills," but also the airline company for enacting a "policy [of] maximum use of automation." [...] The report concludes that "more manual flying would improve pilots’ ability to cope with maneuvering changes."
Errors and malfunctions compounded after the crash occurred. Two of the passengers who were not restrained for landing were ejected from the plane and died. The "disoriented and confused" pilot failed to order an evacuation of the plane. A flight attendant finally did so after seeing flames outside the window. Emergency slides, damaged in the crash, inflated inside the plane's cabin, trapping and injuring two of the flight attendants.
Perhaps the most tragic mistakes occurred by members of the San Francisco Fire Department responding to the crash. According to the report, Yuan was "not appropriately triaged. Multiple personnel believed she was deceased but did not verify their visual assessments." As a result, she was "rolled over by two firefighting vehicles 23 and 34 minutes after the accident." Though it praises the department for rescuing an overwhelming majority of the passengers, the report says that numerous communication and command errors contributed to an atmosphere of chaos during the operation.
The report makes a number of recommendations to reduce the risk of future accidents like this one.