Asiana Airlines Flight 214 Crash at San Francisco Airport raises some familiar safety issues

On July 6, 2013 a Boeing 777-200 operating as Asiana Airlines Flight 214 crashed into a sea wall short of the runway during a visual approach to the San Francisco Airport (SFO). Flight 214 originated in Shanghai China with an intermediate stop in Seoul Korea before reaching San Francisco. There were 291 passengers and 16 crew on board. Two fatalities and numerous passenger injuries have been reported.

In the coming days and weeks the NTSB and other investigators will, among other things, review the FDR -- flight data recorder (which records pilot flight control inputs as well as aircraft systems and engine parameters during the flight); CVR -- cockpit voice recorder (which records the crew conversations during the flight); and, interview the flight crew to determine what may have caused this crash. The NTSB will also analyze the evacuation and emergency response to the crash.

While it is premature to speculate as to the ultimate cause and contributing factors, some preliminary information has already been provided which raises questions that will need to be answered.

After analyzing the cockpit voice recorder, the NTSB Chairperson, Deborah Hersmann, stated "the aircraft was proceeding normally as they descended and there was no discussions of any aircraft anomalies or concerns with the approach." The CEO of Asiana Airlines, Yoon Young Doo, has also preliminarily ruled out engine or mechanical problems as a contributing factor for the crash.

The NTSB has also reported that the aircraft speed "was significantly below" the proper speed for the approach and the crew called for more airspeed approximately 7 seconds before impact. Moments later the aircraft's stall warnings, including an aural alarm and a stick shaker, engaged to warn the crew that the aircraft was about to stall. Less than 2 seconds before impact, the crew attempted to abort the landing and perform a go around but it was too late.

Based on this preliminary information, the NTSB has essentially determined that the aircraft was too slow and too low during the final stage of the approach. Accordingly, the investigation is focused on the crew's experience and training, as well as the pilot's actions during the approach.

This is not the first time that the two major Korean carriers have experienced fatal aviation disasters. KAL and Asiana have had at least a dozen accidents since the mid-1970s. Several of these crashes have occurred as a result of pilot negligence during the landing approach. As a result, the airlines' training programs, safety culture, crew resource management and crew selection procedures were scrutinized by investigators, as well as independent safety experts, in order to ensure the appropriate safety "checks and balances" were in place in the cockpit. Despite these efforts and greater technology, it now appears that Asiana Flight 214 may be the result of a critical break down in cockpit crew coordination. From the human factors perspective there will be many questions, not least among them: Why was the aircraft flying below the proper glide slope and approach speed? Was the landing profile and airspeed different (slower) from other aircraft the pilot had flown? Did the lack of an Instrument Landing System ("ILS") glide slope information contribute to the crash? Were there issues with how the flight crew interacted with the automated systems on board the aircraft that contributed to the crash? Why didn't the more experienced 777 pilot notice the low speed sooner and call for immediate corrective or emergency action? Was the pilot's lack of experience in this model Boeing a contributing factor to the poor approach and should more training without passengers on board be required before passenger carrying flights are permitted?