Bob Clifford Reacts to Asiana Crash NTSB Hearing that Shows Combination of Poor Piloting, Training and Airplane Systems Design

Robert A. Clifford, Senior Partner at Clifford Law Offices, Chicago, is concerned by the information revealed at yesterday’s NTSB Public Hearing on the crash of Asiana Flight 214, a Boeing 777 widebody airliner. The Hearing information indicates that poor piloting, pilot training, and airplane systems design issues likely led to the fatal crash of Asiana Flight 214. While the full NTSB report and Probable Cause statement will not come for many months, the Public Hearing revealed that the Asiana pilots selected an inappropriate flight mode for the autopilot and autothrottle for an approach to land, and then failed to take manual action to control the airspeed and flight path of the airplane until it was too late to prevent the crash. This inappropriate combination of autopilot and autothrottle modes was neither recommended against nor prohibited by Boeing’s Flight Crew Operating Manual (FCOM), and Asiana officials indicated there is no Boeing simulator or operational training for it. In this combination of automation modes, the 777’s autothrottle “wake-up” feature, which is designed to prevent airspeed from decreasing to dangerously low levels, does not function – something the Asiana flight crew apparently was not aware of. Several years before this fatal Asiana crash, flight test pilots and safety officials from the European Aviation Safety Agency (EASA) warned Boeing in a letter notifying Boeing that inconsistent functionality of Boeing’s autothrottle “wake-up” feature could be a “strong contributor to aviation accidents” and told Boeing it would be a safety improvement if this “wake-up” feature were made functional across all Boeing modes of automation. Boeing reportedly chose not to make any changes to their 777 systems but instead alleges that inserted language into their Flight Crew Operating Manual (FCOM) briefly discussing the issue. The circumstances of this crash make it evident that such alleged language in the FCOM was not enough – these pilots were confused by the system, and it resulted in this crash. Clifford agrees with EASA that Boeing should have made the autothrottle “wake-up” feature functional in all automation modes. If Boeing was not willing to do that, Boeing should have, at a minimum, changed its FCOM to prohibit the use, below a reasonably safe altitude and airspeed, of any automation modes in which the autothrottle “wake-up” feature was not functional. Additionally, the 777 low airspeed alerting system that was supposed to prevent such circumstances from resulting in a crash was inadequate to alert the Asiana pilots in time. Boeing’s 777 aural low airspeed alert consists of three short beeps coming from their master caution system. Boeing officials testified that these same short aural beeps can come from 70 to 80 other conditions unrelated to airspeed. The NTSB hearing officials and Asiana executives appeared to take issue with Boeing officials on whether or not these three short beeps are adequate and effective aural warning for a low airspeed condition since they could mean so many different things other than low airspeed. Clifford agrees that the low airspeed alerting system on the 777 is inadequate — as evidenced by Boeing installing a completely different, low-cost, software-driven “LOW AIRSPEED!” aural warning on all 737s in the aftermath of the fatal crash of Turkish Airlines Flight 1951 in 2009. As with the Asiana crash, this Turkish Airlines crash involved a trainee pilot and three other pilots onboard who all apparently expected the autothrottle to prevent their airspeed from dropping too low. With 10 years of NTSB recommendations for low airspeed alerting systems and this recent Turkish Airlines crash, one would have expected Boeing to outfit all of their airplane models with the new “LOW AIRSPEED!” aural warning. Instead, Boeing chose to only equip the 737. Clifford believes that until such time as Boeing adopts a more global approach to incorporating lessons learned and safety features across its fleet, it will not be surprising to see such forewarned, well-understood circumstances to continue to recur and cause further crashes.