Running Head: ASIANA AIRLINE 214 INCIDENT
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Asiana Airline 214 Incident
Brief Description on Incident
On July 6, 2013 a Korean registration Boeing, Asiana Airline Flight 214 took a takeoff
from the Incheon International Airport South Korea and for the San Francisco International
Airport, United States. When the flight reached at San Francisco airport it was crashed that leads
to 3 human life causalities out of 291total passengers on the board, 49 passengers got serious
injuries that also includes the 4 flight attendants and 187 passengers got minor injuries.
According to the report presented by the National Transport Safety Board of United States the
accident was the result of the human error and mismanagement as the flight crew was unable to
handle the situation efficiently on time that leads to the big accident. As the airplane was about to
make the final approach the fight crew mishandled the situation also the multifaceted
documentation of the boeing flight control system and the teaching and instructions to the pilot
of the Asiana Airlines were also termed as the consequence of the accident according to the
United States National Transportation Safety Board report.
Chain of Events
On July 6, 2013 at day time an Asiana Airlines flight 214 that was traveling from Incheon
International Airport South Korea to San Francisco, United States by a Boeing 777-200ER a
regular international flight was smacked against a sea wall at the San Francisco International
airport United State. There were total of 291 passengers travelling through this flight out of
which 3 of the passengers lost lives, 49 passengers including 8 flight attendants and 1 crew
member were seriously injured and remaining got the minor injuries. The damage to the airplane
was caused due to the collision forces and eruption of the fire in its right engine after the
collusion. As the flight attained the visual approach of the runway, the straight-in-visual
approach was set for the flight crew and an instruction was delivered from the traffic control to
the flight for maintaining the 180 knots to 5nm from the runway, at this point the
mismanagement was done by the flight crew and the airplane dive was not done properly that
leads to the mismanagement of the position of the airplane that remained quite above the
preferred glidepath at 5nm point (Stock & Francis, 2014). At this level the dive of the airplane
became challenging for the flight crew and in order to control the descent of airplane and to
attain the preferred glidepath, an autopilot mode was selected by the pilot who was flying the
plan that leads to auto flight mode of the plane and began the mount because of the lower altitude
Asiana Airline 214 Incident
than the desired one. The flying pilot at this moment detached the A/P and converted the thrust
level to inoperative that leads the auto throttle to convert to HOLD mode and this mode the
airspeed is not controlled by the A/T. the captain of the airplane moved the airplane in downward
position and also increased the diving rate. None of the following that is flying pilot, monitoring
pilot and the observer noticed the alteration in the A/T mode to HOLD (Stock & Francis, 2014).
Above the 500 ft above the airport elevation the approach of the Asiana’s should be
stabilized as the precision approach path indicator would have indicated the desired glide path to
the irpalne crew. The speed was also adjusted but the main problem that retained till last was the
idle thrust levers and also the diving rate was 1200 ft per minute that should be 700 ft per minute
to attain the reasonable glide path. These two signs were indicating that the approach adopted by
the fight crew was not reasonable and stable. To make the position of the plane stable the flight
crew at that time period should adopted the go-around approach based on the situation but they
failed to evaluate it due to which the position of the plane become un stabilized with each
passing minute and the PAPI four red lights indicated the diving rate below the glidepath. The
flight crew recognized this problem at 200 ft and still did not make a move for the go-around
until the airplane reached at 100 ft and it this point the go-around does not work. The failure of
the flight crew in efficient evaluation of the airspeed was due to the anticipation, exhaustion and
dependence on the automation (Stock & Francis, 2014).
At the time of the landing the key landing gear and the aft fuselage hit against the
seawall, the back tail of the airplane was broke that moved the airplane off the runway, slightly
lifted in the air, rotated in 330 degrees and hits the ground on final approach. The collision forces
that go beyond the certification limit leads to raise cabin two slides that for the moment trapped
two flight attendants and seriously injured them. Six individuals were evicted from the airplane
out of which two passengers and four flight attendants were seriously injured. The flight
attendant was evicted because of the obliteration of the aft galley present under their seat. The
passengers were evicted because of the absence of the seatbelt out of which two were rolled in
the vehicles. The passengers could have remained safe it they were wearing their seatbelts (Stock
& Francis, 2014).
When the airplane stopped after the hard collision against the sea wall the fire erupted in
its right engine and as soon as flight attendant gauge the fire in the plane and began evacuating
Asiana Airline 214 Incident
the passengers that saved the 98% of the passengers who were successfully taken out of the
airplane by the flight attendant. The fire covered the fuselage, at that moment five passengers
were trapped in the plane that were extracted by the fire fighters, and among the five four were
seriously injured and one lost his life. The report shows that 99% of the total passengers and the
staff present in the airplane were safe while one percent lost their lives. It was all the result of the
mismanagement and the insufficient human understanding that leads to such a big incident
(Stock & Francis, 2014).
Human Factor Contribution
Human error is considered as the main cause of the accidents in aviation industry and it is
also measured as quite similar to the maintenance resources management. Human factor
basically involves the collection and utilization of the abilities and information possess by the
human beings in the aviation industry to make the industry efficient and risk free. The main
characteristic that human being possess is to mold its skills and abilities according to the demand
of the time and in aviation industry nourishing and utilizing the skills according to the advanced
technology adopted by the industry is the main source of advancement and safety. This can be
achieved successfully by providing the proper training to the human resource of the industry to
make the best possible outcome. The advancement in technology in the aviation industry is quite
fast but still the errors on behalf of the human’s accounts greater that leads to most aviation
incidents (Kastrenakes, 2014). No human being is perfect and making errors are common on
behalf of the human beings but it is also true that the errors can be minimized to maximum level
to avoid the high risk problem. In aviation industry human errors are mostly done by
maintenance personnel, flight crew, air traffic controllers and other individuals that are directly
linked to the operations of the airplanes.
Inadequate Pilot Training
According to the reports the co- pilot that was operating the Asiana flight 214 had no
experience of operating a Boeing 777 and was receiving the flight training. The operation duty of
the Boeing 777 was given to the operator was undergoing the flight training this makes the
chances of human error quite high here. Also the instructor pilot of the Asiana flight was
assigned the task of instructing the trainee regarding the landing progress for the very first time.
Asiana Airline 214 Incident
Before this he possessed no experience of instructing any trainee. Both the factors contribute
much to the incident that took place in San Francisco international airport with Asiana Airline
214 flight (Possible, n.d). After the incident took place the airline focused on pilot and crew
training programs to enhance the operational activities of their flights and to avoid the incidents
in near future. The new program adopted by the airline involves the development of the pilots
and other members by initiating enhanced training program for automated flight as well as for
visual approach, the mismanagement of which was the main cause of this incident (“Possible,”
n.d).
Inadequate Knowledge about the Automated System of the Aircraft
The other and the main reason of the incident was the unawareness of the flight pilots
about the automated system of the aircraft as pilots completely relied on the automated system of
the aircraft but they were totally unaware of the automated system operation that results in the
collision of the tail of the aircraft with the seawall due to the slow and low flight (Stock &
Francis, 2014). This depicts the inefficiency of the airline and its management that their flying
pilots were unaware of the automated system of the aircraft and they were given the
responsibility fly the hundreds of individuals that result in risking both staff and passengers lives.
This incident highlights that training of staff should be the main concern of the airline as in this
case an airline totally relied on the inexperience and non-professional staff that results in the
huge loss to the airline. So training is of key importance for overall all the aviation industry
including all the airlines because the advancement in technology and rapid automations of the
aircrafts demands the training of the human resource accordingly to utilize it in more proper
manner (Weikel, 2014).
The findings of the incident clearly identify the human error that was the main cause of
the incident. The inability of the flight captains due to the lack of information regarding the
associated plane that is Boeing 7777 and its automated operating system was the main cause of
the incident. Without human resource it is quite possible to make the effective use of the
technology and to fully utilize the technology it is important to train the human resource
accordingly. In this case of Asiana Airplane incident an airline fully adopted the technological
advancement but failed to educate its staff accordingly that resulted in high risk to the staff itself
along with hundred of passengers travelling with the inexperienced flight captains. As described
Asiana Airline 214 Incident
earlier “Human factor basically involves the collection and utilization of the abilities and
information possess by the human beings in the aviation industry to make the industry efficient
and risk free”. In this case human factor totally fails because of the absence of the information
and ability that is important for the risk free aviation organization. This leads to the inefficiency
of the company and also badly impacts the name and business because after the identification of
the in competencies on behalf of human resource the customers avoid travelling with the related
aviation company. The incident highlights the importance of the human factor and its role in the
efficient performance of the employees and the management.
Outcome of the official report
According to the official report findings mismanagement on behalf of the flight crew and
the lack of proper information is the main cause of the incident. The mismanagement leads t the
increased workload that leads to exhaustion, tension and confusion that made the pilots unable to
detect the signs shown by the airplane and thus failed to bring back the airplane to its normal
position. Now this refers to the lack of training and education to the pilots as one was the trainee
and other was the trainer who for the first time giving training so both of the pilots lacks the
professionalism because professionalism leads to experience and experience enables the human
resource to make the effective decision at the time of time by understanding the demand of time
instead to creating exhaustion and instability at the time of making hard decisions (Dismukes et
al. 2007).
Another error on behalf of the flight pilots occur due to the miscommunication between
the flying pilot and the monitoring pilot that leads to the ineffective operation of the automated
system. This also highlights the lack of education and training regarding the different factors that
are important while carrying a flight. Miscommunication at the time of emergency creates the
great challenge and risk for both the crew staff and the passengers. The proper education and
training to the pilots regarding handling the different situations along with operating the flight is
of key importance for all the airlines. Training is the most important and basic component along
with the clear and defined code of conduct and penalties in case of human error that can
minimize such incident on quite larger level. But it is not suitable to say that different actions
will help in completely eradicating such incidents because humans are made to make errors and
Asiana Airline 214 Incident
the best are those who learn from their mistakes that will definitely help them in reducing the
high risk of occurrence of such incidents.
The report of the incident clearly identifies the human error as the cause of this incident
and the main reason of the human error was the inadequate training to both pilots that is flight
captain and monitoring captain (Weikel, 2014). Training must be provided by incorporating the
latest technology and the automated system installed in the airplanes to enable the pilots
understand the automated system because dealing effectively with the automated system requires
the proper skill and knowledge that can be provided to the pilots by proper training program.
Also the effective and clear communication between the pilots and between captains and the staff
of the flight is very important as without effective communication the risk of misunderstanding
and poor operations increases that creates challenges for the overall flight including pilots, crew
staff and passengers as well.
Applied Changes after Incident in Aviation Industry
Asiana Airline incident raised many questions regarding the human factors and errors in
the aviation industry that has also made the other airlines to think about to avoid any incident in
the future. The technical and non-technical system of the aviation system is becoming
multifaceted similarly the reasons of incident occurring in the aviation industry are also
becoming multifaceted. It has become challenging to segregate the single or few key reasons
among the loads of direct and indirect factors that leads to the advanced incidents. Also the
importance of understanding the human behavior that leads to the incidents in the aviation
industry is increasing to understand that why the related individual took certain step that leads to
error and thus became the cause of the incident. Along with human error the systematic failure,
organizational problems and other factors contributes widely in the occurrence of the incident
but the probability of the human error is quite high in the aviation industry. Many airlines along
with Asiana Airline focused on the staff training after the incident occurs which is the main
cause of the increasing human error (Star Alliance, 2013). Lack of expertise and information
leads to such error and also the weak potential of taking effective decision at the time of need
also lead to such errors. Training of the staff is of significant important for the overall aviation
industry to control the human behavior and make them more potential for effectively handling
Asiana Airline 214 Incident
the situation that leads to the Asiana Airline incident. Following are the applied changes that
were adopted by the aviation industry to avoid such incidents
1. Boeing 777 training program was initiated that helped the flight crew in understanding
the different modes and the automation system of the airplane for its effective operation.
Understanding and making the efficient use of the automated system is quite important
for the advanced aviation industry and the failure in operating such systems effectively
leads to the failure of overall technological advancement of the industry.
2. According to the Safety Recommendation A 14-37 all the operators and the training
providers were required to provide the training to the overall staff and pilots of the
industry related to the operation of the Boeing 777.
3. With the help of the expert panel a proper and effective training programs were initiated
by the companies to make the staff understand the complex system more efficiently that
was important for the successful operations of the complex and technologically advanced
flights.
4. Under the security and safety code of conducts and rules and regulations were clearly
defined by each airline to flight crew and pilots and in case of any mistake heavy
penalties were introduced.
5. The pilots both flying pilot and monitoring pilot with the proper certification and ability
to understand the automated system was then given the duty to take the flight of the
Boeing 777.
6. The qualification and experience criteria of the instructor of the operation was also
revised by many airlines to enhance the instructor role and the expertise because only few
possess the capability of guiding and monitoring the task performed by the trainee. The
instructor requires the bundle of skills to handle the situation in every condition but in
case of the Asiana Airline the instructor totally failed in dealing with the situation
efficiently and smartly.
7. To enhance the abilities of the pilot most airlines have altered the automation policy and
provided the manual flights both during training and in line operations.
These are the few changes that were adopted by the aviation industry after experiencing
the Asiana Airline incident and its root cause that had made the overall industry to look into their
Asiana Airline 214 Incident
system and evaluate whether they are also making the same mistake that Asiana Airline did that
is ignoring the enhancement if the employee proficiency and risking the lives of thousands of
people travelling through the chosen airlines. The overall industry recognized the importance of
the human resource training to make them able to deal with the complex and automated system
of the airplanes to make the journey safe for both passengers and airline itself. The proper
regulations were introduced in the aviation industry and within each airline to keep the
maintenance of both the operational system and the flight crew abilities to enhance the
operational activities. Such actions also results in bringing back the trust level of the customers
that most airlines lost due to the inefficiency and poor performance by their pilots.
Formulated Policy
The formulation of policy is quite important for all the airlines to decrease the effect of
the human factors in the aviation industry because the aviation industry has termed the human
error rather than mechanical errors as the main and basic reason of the most of the aviation
incidents that took place in different parts of the world. Despite of the rapid technological
advancement, humans are accountable to guarantee the accomplishment and protection of the
aviation industry. So it is important for the human resource to be educated, flexible, devoted and
competent while implementing the decisions and the judgment. This is the reason industry is
investing more in the training of the human resource, equipment and the system and all these
components possess the long-term inference. As technology is growing so rapidly that it is not
possible to forecast immediately the interaction level of the human being with the change in
technology, so it is not viable for the industry to depend largely on the experience and
perceptions to make the decisions regarding the performance of persons. As a substitute a
reliable scientific foundations is required for evaluating human performance allegations in
structure, training and measures.
The effective policy regarding the training of employees in the aviation industry is of foremost
importance. The human errors can be controlled by proper training program. The certification
with the advancement in the system and advanced technology should be made compulsory for
the employees of each stage especially for the cabin crew including pilots (flying pilot and
monitoring pilot). Only the pilots with the certification related to the advanced systems should be
made allowed to operate the system and carry the flight. Higher the certification level more
Asiana Airline 214 Incident
compensation and benefits should be offered to the pilots. The responsibility of the instructing
the pilots and monitoring them should be given to the individuals that have enhanced their skills
through different training sessions. Companies should introduce the level and the levels and the
related benefits of each level and make it the responsibility of the human to strive hard to attain
the higher level and enjoy the more benefits. After each training session to check the abilities of
the individuals it will be essential for them to go through the little exam. The know hoe of the
advanced automated system is quite important for every staff member who will be dealing with it
so before adopting the system the humans should be introduced tom such systems and should be
informed enough about the use of the system. This will be a little costly for the airlines to carry
out all the steps but for the safety and the reliable flight it is important to keep the human
efficient and well informed to handle the entire situation effectively.
Asiana Airline 214 Incident
References
Dismukes, R.; Berman, A.B.; Loukopoulos, L.D. (2007). “The Limits of Expertise: Rethinking
Pilot Error and the Causes of Airline Accidents.” Studies in Human Factors for Flight
Operations. Ashgate; Aldershot, England.
Kastrenakes, J. (2014). Asiana Airlines crash in San Francisco blamed on overuse of autopilot.
Retrieved from http://www.theverge.com/2014/6/24/5838072/asiana-airlines-flight-214-
crash-autopilot-issues-at-fault-ntsb-find
Martinez, M. (2016). A year later, survivors recall Asiana Flight 214 crash. Retrieved from
http://www.cnn.com/2014/07/06/us/california-asiana-plane-crash-anniversary/
Possible Causes of the Asiana Flight 214 Crash. (n.d.). Retrieved from
http://www.kreindler.com/Possible-Causes-of-the-Asiana-Flight-214-Crash.shtml
Stock, S., & Francis, M. (2014). Asiana Pilots Didn't Understand Automated System: NTSB.
Retrieved from http://www.nbcbayarea.com/news/local/NTSB-Cause-Asiana-Airlines-
Flight-214-Crash-SFO-264389901.html
Star Alliance. (2013). “Member Airlines”
http://www.staralliance.com/en/about/airlines/asiana_airlines/#
Weikel, D. (2014). Asiana pilots switched off system that might have averted crash: NTSB.
Retrieved from http://www.latimes.com/local/lanow/la-me-ln-hearing-asiana-crash-
20140623-story.html
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Appendices
Appendix A
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Appendix B
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