Asiana Airlines Flight 214 crash-arrived at San Francisco International Airport on July, 2013. There were 307 individuals aboard the plane. One traveler was murdered and 182 were harmed. A second traveler likewise kicked the bucket, yet it is conceivable that she survived the crash and was run over by a flame truck. At the point when the plane was coming into area, the motors were unmoving and the plane was flying much slower than it ought to have been. 1.5 prior seconds the plane crashed, the pilots attempted a go-around, however they were past the point of no return.
The aircraft which crashed was a Boeing 777-200er, and it had been utilized by Asiana Airlines since March 2006. The crash was the first run through anybody ever passed on aboard a Boeing 777. Just two of the 307 passengers and team ready for kind sized plane kicked the bucket in the July 6 crash. Close void fuel tanks and plan upgrades helped to keep aluminum body of a plane to a great extent entire, and scores of safety adjustments received since the 1980s, the crash landing of Flight 214 got to be fundamentally a story of survivability rather than debacle (Chappell & Bill, 2013).
Despite the fact that there are numerous components which has been distinguished as a cause of this crash however the a percentage of the primary driver was the lack of fitting training of polit. Boeing told the examination group and Board parts, there was nothing the issue with the plane, and the crash was caused by the disappointment of the pilots to keep up speed and to prematurely end the landing when the methodology had ended up unsteady, as needed by their organization's arrangements.
A temperamental methodology happens when a plane's speed or rate of drop is excessively quick or to abate, or the plane isn't legitimately adjusted for landing. Among the slips were that pilots didn't take after organization strategies when they neglected to get out notices about the plane's height, speed and moves they were making amid the landing methodology (Sang-Hun & Choe, 2013). The pilots were not observing the plane's airspeed a principal of flying. They accepted the auto throttle was maintaining the obliged speed for a safe landing.
Weather
The weather at San Francisco International Airport on the day of the crash was nothing out of the ordinary. The winds were blowing at 15 knots, gusting at 20 knots and visibility was more than 10 statute miles. There was few clouds that afternoon and with no ceiling. With these conditions the weather seemed to not have any factor to this crash. The airport lies on the west side of the San Francisco Bay which in this area experiences often breeze off the water. The final approach path to runway 28L lies over the water and so pilots usually experience variable winds while on final.
Airport Information
San Francisco Airport (KSFO) is the largest airport in the bay area, and second busiest after Los Angeles International Airport in California. KSFO is located approximately 8 miles southeast of San Francisco, California. It is owned and policed by the City and County of San Francisco. KSFO have four runways, 10L/28R, 10R/28L, 1R/19L, and 1L/19R. KSFO is a class B airspace. According to average analysis ending on 12 December 2013, KSFO serves 1176 aircraft operations, of which 75 percent are commercial, 20 percent are air taxi, 3 percent local general aviation, 2 percent transient general aviation, and about 1 percent military operations.
Aircraft & Pilot experience
On 6th July, at about 11:28 Pacific daylight time, Asiana Airlines flight 214 struck the seawall at San Francisco International Airport. The aircraft was a Boeing 777-200ER, which had a Korean registration HL7742. The plane had two hundred and ninety one passengers. Three of these passengers were fatally injured. Forty passengers and eight out of twelve flight attendants, and one of the crewmembers got serious injuries on their bodies (Toh 1). The flight used to make regular trips from Incheon International Airport.
The pilot who was in charge of the plane had little experience having only flied for 43 hours in this aircraft. Furthermore, it was his first time to fly into this airport with this type of an aircraft. Nevertheless, he has flown Boeing 737,747 and even Airbus A320 for 9,793 hours. Therefore, he had more experience on other aircrafts than this plane. However, the co-pilot was highly experienced having flew for 12,842 hours (Toh 1).
According to the national Transportation Safety Board which together with other investigative bodies carried the investigation on the cause of the accident, there was no mechanical error that could have led to the crash. Therefore, they narrowed down on the actions of the pilots in order to come up with an in-depth conclusion. According to the final report, the crash occurred as a result of mismanagement of approach and poor monitoring and management of airspeed. Despite the experience of the two pilots, they failed to use the experience on other aircrafts to manage the airspeed, an aspect that could have prevented the crash. According to the findings, the qualification and certification of the flight crew together with their behavior or even medical condition did not lead to the accident (National Transportation Safety Board 1). In addition, maintenance, air traffic controllers, or even preimpact structural engine had nothing to do with the crash.
The glideslope was not functioning. However, this could have alerted the pilots to use visual approach. The crew mismanaged the vertical profile of the plane, an aspect that made the airplane to be above the required glide path by the time it got to five nautical mile point. This made it hard for the crew to achieve the stabilized approach. Furthermore, this error also resulted to a period of increased workload. As a result, it made it hard for the pilot to become aware of their actions, an aspect that delayed the activation of automatic airspeed control. Moreover, there was a delay in the initiation of a go-around by the pilot (Toh 1). Then, when the pilot became aware of the low path by the airplane, they were surprised and confused an aspect that led to poor communication.
Poor training was pinpointed as another cause of the accident. The pilots did not know how to react effectively after the failure of the equipment. Therefore, the pilots could have been in a better position if they knew how to navigate the aircraft after the failure of the equipment (Kim, Lyanne, Katie, and Matt 1). This could have prevented the accident and made it possible to land safely through quick intervention and use of flight automatic system.
Probable Cause
On June 24th, 2014, The NTSB determined that the root cause of the accident was in fact pilot error along with over reliance on automated systems. The NTSB determined this by looking at the data from the black box and Cockpit Voice Recorder (CVR). They determined that the cause was attributed to the flight crew mismanagement of the initial approach. It was determined that the Boeing 777 was higher than the intended glide path. The captain as a result erroneously selected an incorrect autopilot setting that disengaged the autothrottle resulting in loss of control of the airspeed. The 777 then descended lower than the intended glide path without the crew’s knowledge. The crew then realized it and called out for a “Go-Around” or an abort of the landing. This call was given too late and without enough altitude to recover. An undisputed contributing factor to the accident was the crew’s over reliance on the automated systems as well as the crew’s failure to monitor the airspeed as well as the altitude at the appropriate times.
Another contributing factor to the accident was Asiana's policy of using the automated systems during approaches and other important operations. Additionally, it was concluded that both pilots were rather fatigued due to an increased workload. Another probable cause was cited as “failure to follow standard operating procedures”. The pilots neglected to acknowledge common rules and guidelines for shooting an approach. Combined, all these factors led to the crash of Asiana Flight 214.
Findings
There were so many findings from the NTSB investigation. Following are some of the findings that came out from the investigation:
- Flight crew certification and qualification, flight crew behavioral or medical conditions or the use of alcohol or drugs, airplane certification and maintenance, impact of structural factor, engine, or system failures, or air traffic controllers of handling the flight were not involved or cause for accidents.
- Instrument glide slope in the aircraft was not working at the time of crash, but pilots should had successfully landed flight safely using visual approach.
- There was mismanagement by pilot in terms of vertical profile during the initial approach of flight, resulted in flying the aircraft high above the glide slope when it got closer to airport, roughly around 5 NM. Flying above the glide slope put more pressure on pilots to get back on glide slope to do a stabilized approach.
- Firstly the flight was above the glide slope, but while the flight was 200 feet from ground one of the flight crew member became aware of the low airspeed and flight is below glide slope path. Even after becoming aware of this flight condition, flight crew member did not initiate go-around but continued the flight.
- Flight crew has a long work day, which make them feel tired. This condition is called fatigue. Most likely because of fatigue, there was lack of performance from the flight crew members during the approach.
- There was lack of focus on monitoring airspeed during the approach phase of flight, which resulted in increased workload.
- There were nonstandard communications between both pilots while shooting the approach at KSFO, likely resulted in role confusion and degraded their awareness of autopilot flight director system and auto-throttle modes.
- After the impact, there was little delay of about 90 seconds in evacuation because of the pilot monitoring commands not to begin immediate evacuation, and also because of dis-orientation and confusion.
- There was lack of knowledge and prioritizing the emergency task at the KSFO airport, which did not let to more injuries to the people but demonstrated the potential of strategic and tactical challenges that would have led from the decisions made by the aircraft rescue and firefighting department.
- Alert 3 section of KSFO‘s emergency procedures manual was not sufficiently providing information and guidance to anticipate and prevent the problems that might have occurred from the accident response.
Recommendations:
The NTSB recommended to the FAA that there should be an improvement in the courseware, documentation. The training for instructors was also recommended that it should be modified. General training should be developed on the automatic throttle mode and its activation Logic Boeing should be required by the FAA to revise its Flight crew training Manual stall protection demonstration. An explanation and demonstration of the circumstances in which the automatic throttle does not provide low speed protection should be included
The NTSB recommended Asiana pilots to adhere to the standard operating procedures which involves the inputs to the operation of auto flight system controls on the 777 mode control panel and the performance of related callouts.
Also, NTSB recommended Asiana to revise the flight instructor operating experience qualification criteria; a more experienced instructor should be used in the training and observation of the other flight instructor before the ne instructors are appointed.
The NTSB urged Asiana to modify their automation policy to provide for more manual flight, both in training and in line operations, this will in turn improve pilot proficiency.
The NTSB recommended that Boeing should develop and evaluate a modification to Boeing wide-body automatic flight control systems. This is to help ensure that the aircraft energy state remains at or above the minimum desired energy condition during any portion of the flight.
The NTSB recommended that a specific statement should be included that when the autopilot is off and both flight director switches are turned off, the automatic throttle mode goes to speed (SPD) mode and maintains the mode control panel-selected speed.
The NTSB recommended that the Rescue and Firefighting group should work with medical and medico-legal professional organizations to develop and distribute guidance on task prioritization for responding aircraft rescue and firefighting (ARFF) personnel. This includes best practices to avoid striking or rolling over injured or deceased persons with the rescue vehicle.
The NTSB also recommended that the Rescue and Firefighting group along with the FAA should develop and distribute guidance and training materials to ensure that all airport and mutual aid firefighting officers who are placed in command at the scene of and aircraft accident should have at least a minimum level of training.
The NTSB recommended that the City and County of San Francisco should integrate the use of all San Francisco Fire Department medical and firefighting vehicles in future disaster drills and preparatory exercises so that they are well prepared for incidents or accidents like this.
Conclusion
I can say that the Asiana crash was a heartbreaking occasion however one from which associations ought to figure out that it is so critical to have routinely upgraded crisis management arrangements and crisis correspondence methodologies set up. It likewise highlights the criticalness of comprehension the force of online networking in a crisis and how to captivate with it adequately to achieve clients and invested individuals. For some individuals, getting on an airplane is a danger they are ready to take for the accommodation it offers. Furthermore, air head out will probably keep on getting more secure later on. Watchful group screenings, thorough prerequisites for pilots, and better, stronger, stronger airplanes will all assistance to improve the flying experience and ensure passengers from mischief, even in the occasion of the unforeseen.
References:
Ntsb.gov,. (2014). Board Meeting: Crash of Asiana Airlines Flight 214. Retrieved 25 November 2014, from http://www.ntsb.gov/news/events/2014/asiana214/abstract.html
Kim, Lillian, Lyanne Melendez, Katie Marzulo, and Matt Keller. "NTSB cites pilot 'mismanagement' in fatal Asiana Airlines crash at San Francisco International Airport | abc7news.com." ABC7 San Francisco. N.p., 2014. Web. 12 Nov. 2014. <http://abc7news.com/news/ntsb-releases-final-report-on-asiana-airlines-crash/136272/>.
National Transportation Safety Board. "Board Meeting: Crash of Asiana Airlines Flight 214." NTSB - National Transportation Safety Board. N.p., 24 June 2014. Web. 12 Nov. 2014. <http://www.ntsb.gov/news/events/2014/asiana214/abstract.html>.
Toh, Mavis. "Asiana pilot landing crashed aircraft was new to 777 - 7/8/2013 - Flight Global." Aviation News | Aviation Industry & Airline Statistics. N.p., 8 July 2013. Web. 12 Nov. 2014. <http://www.flightglobal.com/news/articles/asiana-pilot-landing-crashed-aircraft-was-new-to-777-388013/>.
Airnav.com,. (2014). AirNav: KSFO - San Francisco International Airport. Retrieved 25 November 2014, from http://www.airnav.com/airport/KSFO
OZ 214/06 JUL/ICN-SFO (1st ed.). Retrieved from http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F538411.pdf
