The NTSB last week distributed 27 safety recommendations before issuing its findings on the probable cause of the July 6, 2013 crash of an Asiana Airlines Boeing 777 just short of Runway 28L at San Francisco International Airport. The majority of the recommendations were issued to the FAA, with the remainder divided among Boeing, Asiana Airlines, the Aircraft Rescue and Firefighting Working Group and the city of San Francisco. The NTSB found the Asiana pilots were primarily responsible for the accident because they mismanaged the final approach path and inadequately monitored airspeed. “The captain selected an inappropriate autopilot mode and took other actions that, unbeknownst to him, resulted in the autothrottle no longer controlling airspeed,” said the NTSB’s June 24 report. Three people died in the accident, including two women who were ejected from the rear of the airplane on impact. The NTSB believes two of the women killed were not wearing seat belts at the time of the accident. One hundred eighty-nine others were injured, 49 of them seriously.
In a question-and-answer session following the presentation of the report, board member Robert Sumwalt challenged publicly raised doubts over the competence of the Asiana crew. “I don’t happen to believe this accident is about crew competency,” he said. “Yes, the instructor pilot could have been better trained to oversee his trainee, but the pilot flying had over 10,000 hours. I think this is a case of the pilot flying expecting the aircraft to do something…it was not designed to do. That expectation came from training that may have misled him, but also from documentation that our investigation showed was not totally clear…The ground instructor who taught the pilot monitoring [on this flight] described the autothrottle going into the hold mode as an anomaly. It’s not an anomaly. It’s the way the aircraft was designed to operate.” Sumwalt indicated that he had learned from other Boeing 777 operators that the aircraft’s autothrottle hold mode is not well understood.
The NTSB posted an animation of the flight’s final approach.