1) The pilots of Asiana Airlines Flight 214 knew the plane's speed was too low as it approached the runway in San Francisco, but did not correct it until just before crashing. 2) Cultural factors may have played a role in the pilots' reluctance to abort the landing, as the pilot flying felt he lacked authority to make that decision himself. 3) The crash highlighted issues with pilots relying too heavily on autopilot systems, as the Asiana pilots did not understand that the autopilot would not maintain speed in a particular flight mode.

1. Asiana crash pilots knew speed was low, hesitated
Asiana crash pilots knew speed was low, hesitated - Yahoo News
By Alwyn Scott
WASHINGTON (Reuters) - In the crucial minutes before an Asiana Airlines flight crashed in San
Francisco last summer, the pilots voiced concern about the plane's low speed but did nothing to
correct it until just before it hit the ground.
A hearing on Wednesday into the July 6 crash that killed three people and injured more than 180,
highlighted the pilots' mistaken reliance on the autopilot to maintain their airspeed but also Korean
cultural factors that may have played a role and the design of the flight controls.
The pilot flying the plane was "stressed" about hand-flying the plane, according to interviews with
National Transportation Safety Board investigators, and hesitant about aborting the landing because
he felt the more senior pilot observing him should make that call.
Asiana Airlines Inc Flight 214 came in too slowly and too low, causing the plane's tail to hit a seawall
short of the runway. The plane spun 330 degrees as it broke apart and caught fire, strewing
wreckage along the runway.
It was the first fatal commercial airplane accident in the United States since February of 2009 and
the first fatal accident for Boeing Co's 777 airliner since it entered service in 1995.
There was no indication of mechanical problems with the plane.
The crash has sharpened a debate on whether over-reliance on autopilot systems in modern aircraft
has led to degraded human flying skills and increased the risk of accidents.
There is "an issue in aviation" with cockpit automation, NTSB Chairman Deborah Hersman told
reporters covering the board's hearing but she added that the airline industry has a robust safety
record.
Hersman said the agency has no immediate plans to make recommendations from the hearing, but if
it finds a safety issue, it can make recommendations at any time.
The NTSB typically takes 12 to 18 months to complete a major investigation.
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U.S. National Transportation Safety Board
(NTSB) photo shows the wreckage of Asiana Airlines Flight ...
TRAINING, RESCUE RESPONSE

2. The hearing also questioned the pilots' training and the rescue response. One of the victims died
from being struck by a rescue truck after the crash.
Training has been central to the investigation because although the pilots had many hours of flying
experience, Lee Kang-kook, the pilot flying the plane, was making his first landing of a Boeing 777
jet in San Francisco. His supervisor, Lee Jeong-min, was making his first flight as a trainer.
The Asiana pilots said in interviews with the NTSB that they left their "flight director" system, which
includes the autopilot, partly on.
But in that mode, the system would not "wake-up" from hold mode, testified Captain John Cashman,
a retired Boeing 777 test pilot, at the hearing on Wednesday. The lack of wake-up meant the
autothrottle was not going to prevent the plane's speed from slipping below the minimum needed to
keep it aloft.
The design is consistent with Boeing's philosophy of leaving the pilot in charge of the controls. "We
try not to put in design elements that override the pilot," Cashman said at the hearing. "We try to let
him be the decider."
Cashman said the design principles had been consistent for 31 years, across Boeing's 747, 757, 767,
777 and 787 models.
SPEED CONCERNS
The pilot flying the plane, Lee Kang-kook, told investigators he was worried about his ability to
perform a "visual approach" to the airport, which is known for having a challenging landing. He had
only performed a manual landing at that airport once before, on a Boeing 747, according to the
NTSB.
On July 6, he was instructed to do a manual landing because a "glide slope" system at the airport
was out of service.
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The National Transportation Safety Board
(NTSB) Investigator in Charge Bill English (R) and Chairman ...
As the plane neared the runway, a number of warnings in the cockpit indicated that the speed was
dropping dangerously, according to the NTSB documents.
In interviews with the NTSB, the pilots said they thought the autothrottle would correct the speed.
The training pilot, Lee Jeong-min, and a third pilot, Bong Dongwon, who was in a jump seat in the
cockpit, spoke about the plane's speed and "sink rate," or descent, about a minute before the plane
hit the ground, according to a transcript of the cockpit voice recorder released on Wednesday.

3. "Sink rate, sir," Bong said, about a minute before impact. "Sink rate, sir," he repeated.
"Minimums, minimums," said an electronic voice about 20 seconds later. "Speed," the instructor
pilot said about six seconds before impact. "Speed."
The pilot later told NTSB investigators he did not feel he had the authority to abort the landing and
perform a "go around."
Asked whether he could have done that maneuver, he said, "that's very hard" in Korean culture
because people at "one step higher level" had to make the decision to go-around.
WAKE-UP CONCERN
Much of the hearing addressed the use of automated systems on aircraft, which are widely credited
for the safety of modern air travel because they can minimize mistakes.
But they can also confuse pilots, experts said on Wednesday, particularly when pilots don't
understand what "mode" the automation is in.
"Problems have been observed on a large number of cockpits and for pilots at different level of
experience," said Nadine Sarter, a professor at the University of Michigan and an expert on flight
control automation.
Bob Myers, chief of flight deck engineering for Boeing, said that if pilots are concerned about how
their plane is flying under automation, the Boeing 777 system allows them to quickly exit that
system and fly the plane manually.
The Asiana pilots said they thought the autothrottle would "wake up" and prevent the speed from
falling dangerously low.
That confusion also arose in 2011 during certification of Boeing's 787 Dreamliner, which has a
similar autothrottle system, documents released on Wednesday showed.
In an interview following the Asiana accident, Eugene Arnold, a test pilot for the Federal Aviation
Administration, said he was surprised when the 787 autothrottle did not "wake up" while set in
certain "modes" but did wake up in other settings.
According to NTSB documents, he thought "it was a less-than-desirable feature and it could be
improved upon."
Boeing did not change the system, saying the autothrottle had been certified and had no problems in
service.
The European Aviation Safety Agency (EASA) called the two modes with no wake up feature an
"inconsistency" and suggested changing the system to avoid confusing pilots, EASA wrote in a report
to the FAA before it certified the jet in 2011, cited by Arnold.
"Inconsistency in automation behavior has been in the past a strong contributor to aviation
accidents," EASA said.
Boeing says in the 787 operating manual that in certain flight modes, the autothrottle "will not wake

4. up even during large deviations from target speed and does not support stall protection." The matter
is also noted in the 777 operation manual, but in more abbreviated form.
(Reporting by Alwyn Scott; Editing by Jeffrey Benkoe, Gunna Dickson and Tim Dobbyn)
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