Asiana Flight 214 on runway. Photo by NTSB [Reuters]Since the crash of South Korean Asiana Airline’s Flight 214 on July 6, 2013, a growing body of evidence indicates the crash was caused by human error. Flight 214 was arriving at San Francisco International Airport after an 11-hour flight from Seoul, South Korea. During its landing approach, the Boeing 777’s dangerously slow speed and rapid descent to low elevation caused the plane to hit a seawall short of the runway. The collision broke off the plane, sending the plane into a spin, and soon bursting into fire.

Of the 307 people on Flight 214, there were 16 crew members and 291 passengers. Known nationalities of the passengers included 77 Korean citizens, 141 Chinese citizens, 61 US citizens, and 1 Japanese citizen. Only three died while the rest luckily survived the crash. The three dead were all Chinese teenage girls. One, a 16-year old girl from China who survived the crash, was struck by an emergency fire vehicle responding to the crash.

Asiana Flight 214 rear without tail. Photo by NTSB [Reuters]The National Transportation Safety Board (NTSB) is still conducting an investigation. There is no official report yet. NTSB is focusing primarily on landing procedures and speed, indicating their interest in human factors that might have contributed to the crash.

The Asiana Pilots Union and Air Line Pilots Association of Korea released a statement on July 21 voicing “concerns about the possibility of inaccurately identifying the cause of the accident”.  They stated, “Accidents that occur in aviation are not due only to a single cause, but from many causes. The list of causes often includes defects in aircraft, airline policies, pilot duty hours, working environment, issues which hinder the safety in the aerodrome area, weather conditions, ATC situations, and pilot error…” The union concluded saying they are working with the International Air Line Pilots Association and sent a pilot to work with the investigation.

So what are these factors?

  • Pilots were being told by air-traffic controllers at the San Francisco International Airport to use visual approaches on the day of the accident because the airport’s glide slope, which helps line up the correct path to the runway, was closed for construction.
  • Deborah Hersman, NTSB chair, said, “The pilot that was sitting in the jump seat, the relief first officer, identified that he could not see the runway… from his seated position. And that the aircraft – the nose was pitched up, so he couldn’t see the runway,”
  • The pilot flying the plane turned off the autopilot at 1,600 feet altitude, 82 seconds before the crash. Seconds later, at 1,400 feet altitude the plane was flying at 196 mph. As the aircraft approached the runway, it was flying 119 mph three seconds before impact. This is almost 40 mph or 25% slower than the target landing speed of 158 mph.
  • After the plane descended below 500 feet, the point at which Boeing advises pilots to abort if they aren’t sure the landing is set up properly, Flight 214 pilots did not mention the plane’s speed until after an automated system called out an altitude of 100 feet, only seconds before it hit a seawall. Auto-throttles that could have reacted to compensate for needed speed were not turned on.
  • Asiana Flight 214 pilots didn’t attempt to abort their landing and add power to raise elevation until less than 3 seconds before it struck the seawall, according to NTSB.
  • Upon impact with the seawall, the landing gear broke off. Then the tail of the plane snapped off, and the plane began to toss, turn, spin, and skid. The plane came to rest adjacent to the runway.
  • The pilot at the controls, Lee Kang Kuk, had almost 10,000 hours of flight experience. He was an experienced Boeing 737 and 747 pilot, having led 29 flights of the 747 to San Francisco. He was halfway through training for the wider Boeing 777. “To complete initial operating experience for Asiana, he’s required to have 20 flights and 60 flight hours. He had 10 legs – he had completed 10 legs. And about 35 hours flying the 777,’’ Deborah Hersman said.
  • A management captain sat in the co-pilot’s seat, serving as flight instructor to train the pilot. He is an experienced Boeing 777 pilot. “He reported that this was his first trip as an instructor pilot,” Hersman said. Adding, “The instructor pilot stated that he was the pilot in command. This was the first time that he and the flying pilot that he was instructing had flown together.”
  • Another pilot aboard to give the primary pilots a rest break was seated in the rear of the cockpit.
  • The fourth pilot – the relief captain – was in the cabin and not in the cockpit at the time of the crash.
  • The San Francisco Chronicle reports, that NTSB Chair disclosed that the pilot at the controls said, he the plane crossed 500 feet altitude something flashed in his eyes, temporarily causing him to lose visibility.
  • A flight attendant initially asked the pilots whether she should begin an evacuation, but Hersman said she was told not to, as the pilots were apparently still consulting with flight control. An announcement was then made over the intercom telling passengers to “stay in your seats,” Hersman said. This delayed the evacuation for 90 seconds.
  • A cabin manager in the middle of the airplane then noticed a fire outside the craft and asked a flight attendant to tell the crew. That’s when the evacuation began, Hersman said.
  • Asiana Airlines attendants won high praise for calmly and bravely helping passengers to safety.
  • Two evacuation slides on the doors inflated inside the cabin instead of outside, pinning two flight attendants to the floor, and breaking the leg of one attendant. Crew members deflated the slides with axes to rescue their colleagues, one of whom seemed to be choking beneath the weight of a slide. This limited the choice of exits, though the plane rested on the level ground.
  • Some passengers in First or Business-Class, or towards the front, were able to flee the plane on a slide, and even leave with their carry-on luggage. The rear of the plane suffered more damage on impact, and more chaos, with the overhead bins opening and luggage falling onto passengers.
  • Some passengers assisted in evacuation. Cited in the New York Times, Passenger Benjamin Levy, in Seat 30K, opened an emergency exit and helped several dozen passengers exit the plan, many children among them, as the plane caught fire and smoke filled the cabin. Then fire fighters arrived.
  • Cabin manager and flight attendant Lee Yoon-hye is described as apparently the last person to leave the burning plane. She is among those being called out for her heroic efforts to lead fliers to safety.
  • Three our of the four flight attendants who had been seated in the back of the plane were ejected – in their seats – from the aircraft when the tail section broke off and the plane began to spin.
  • Two 16-year old Chinese girls, Ye Meng Yuan and Wang Linjia, who were sitting together towards the rear of the plan, were found on the ground outside of the plane. They both attended Jiangshan Middle School in Zhejiang, China. Along with 34 10th-grade students from China on Asian Flight 214, their destination was to attend West Valley Christian School outside Los Angeles  for three weeks this summer.
  • Wang Linjia died on July 6 at the crash scene.
  • Ye Meng Yuan was run over by a fire truck while laying on the ground. She died of multiple blunt injuries consistent with being run over by a motor vehicle.
  • 181 were injured. Several were still in critical condition several days after the crash, at San Francisco General Hospital.
  • The third crash victim, 15-year-old Liu Yipeng, died at the hospital on July 12.

Hero and Flight Attendant Lee Yoon Hye. AP file photo by Jack Chang.U.S. investigators are trying to determine why the pilots didn’t react to the critical loss of airspeed until seven seconds before the crash. Deborah Hersman said that investigators were listening to recordings from Flight 214 to review the “tone and demeanor” inside the cockpit and see whether junior pilots felt safe challenging their superiors. This is in reference to previous crashes where junior pilot did not speak out or correct their superiors because of cultural norms.

Bloomberg reports, Asiana pilot flight manuals, and Korean pilots as a whole, put over reliance on flying using autopilot. They train less with manual flying. As a result they have less comfort and experience with manual or visual landings, compared to American counterparts particularly those with military flight experience and extensive manual flying experience. The lack of hands on experience is a handicap when the need arises for split-second manual maneuvers.

Another issue now being raised is whether plane seating should be equipped with over the shoulder seat belts and not just waist belts. Waist belts alone are known to produce potentially fatal injuries on the impact of a crash. Waist belts were the first generation safety harness, and replaced by shoulder belts long ago in automobiles. With plane take-offs and landings at high accelerations and speeds, the application of waist belts somewhat of a false security and incongruent with its safety purpose.

Two months earlier, the South Korean government asked Asiana to improve pilot training and strengthen safety measures. According to Kwon Yong Bok, director general of aviation safety policy at the Ministry of Land, Infrastructure and Transport, new measures to improve safety and manage Asiana’s expanding business growth, were close to implementation before the crash.Last week, the South Korean government said will promulgate stricter aviation rules in about three months to address concerns the crash raises about the nation’s safety regulations. Director General Kwon said South Korean authorities met Asiana’s officials on July 15. According to Kwon, Asiana has announced plans to conduct special training for all its pilots on landing on visual approach and to strengthen training on landing at airports that lack systems to help planes touch down. Asiana also pledged to adopt fatigue risk management systems, improve communication in the cockpit, and open a second hangar at Seoul’s Incheon airport to increase its aircraft maintenance capability, said Kwon.