Essay on Human Factors That Caused Crash of Asiana Flight 214

Published: 2021/12/02
Number of words: 1497


The Asiana flight 214 accident happened on July 6, 2013, when the flight hit the Seawall at the San Francisco international airport (Surges,2014). The accident occurred at 11: 28 am. During the crash, three out of 291 passengers aboard the plane were fatally injured. Forty passengers received minor injuries. One of the passengers who had not tied his seatbelt was thrown out of the plane. About 248 passengers aboard the plane were not injured. The flight was a Boeing 777-200ER registered as HL7742. It was operating on Pratt and Whitney (PW4090) engines. By the time of the random crash, the flight had accumulated over 37000 flight hours and slightly over 5000 takeoff and landing cycles. According to the NTSB, misuse of the autopilot systems and inadequate monitoring of the flight instruments were the main reasons behind the accident. The primary purpose of investigating the accident was to know whether human actions played a role in the accident. As it has been reported by the NTSB misuse of the autopilot systems and insufficient monitoring of the flight instruments were the principal reasons for the accidents. They were either caused due to fatigue, inexperience or lack of coordination between the PM and the PF of the flight. It is important to note that after the crash, the four pilots on board the flight were fired. Besides, there have been mixed reports about the competence of the PF. Consequently, it is essential to investigate the underlying human factors behind the reason so that in future such accidents can maybe be prevented.

Human factors elements

According to the NTSB, the main reasons behind the accidents was the misuse of the autopilot system and the reduced monitoring of the flight’s instruments. Apparently, all these reasons are related to human actions.

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Visual Approach

The relief pilots had taken over the flight for four hours en route allowing the PM and PF to rest. The PF took in charge of flight when it was about two hours to San Francisco. The relief pilot had set the ILS approach to runway 28L in the flight management system. It is clear that the PF had intended to use the ILS localizer to maintain the horizontal path to the runaway and the autopilot system to keep the vertical profile of the plane. As the plane was nearing the airport, the airport controllers asked the pilots if they had the airport in sight to which they responded in the affirmative. During the plane’s descent, the flight’s autothrottle system was in the hold mode. Besides the autopilot, the system was in the FLCH SPD pitch mode and the HDG-SEL rolling mode. In this mode of operation, the autopilot would hold the heading mode selected by the pilots in the Mode control panel (MCP).Again the autopilot would be in charge of the charge of elevator positions of the flight. Also, what this meant is that the thrust levers would remain in their positions unless manually moved by the pilot since the AT mode was set to the HOLD mode. This later proved a hindrance in initiating a go round. Besides, it made it difficult for the pilot to be aware of the changes in the speed that were being experienced. Again, the Automatic terminal information service reported that the glide slopes of the ILS approach to runaway 28L were out of service. This demonstrates the caveats of the pilots’ overreliance on the autopilot system.

Situational awareness

Asiana flight policy put much emphasis on full automation during the flight’s line operation. The company policies were against manual coordination of the flight. Consequently, what this meant was that the PF was unable to recognize the flight reducing speed and apply corrective action of increasing power to increase the speed of the flight. Due to the overreliance on the automation, the pilot was unable to use the pitch control of the plane efficiently. Thus, the flight handling skills of the PF were not up to par due to the overreliance on automation. Again, despite the fact that the PM was an experienced pilot with approximately 12000-flight hour experience, he had never before supervised a trainee pilot during the flight’s line operations. In fact, this was his first supervisory role. Due to this, the PM was least suited to handling the dynamics and unpredictable instances that an instructor has to contend with during the training of trainee pilot. It was little wonder he was unable to note the decaying speed of the plane.The coordination between the two pilots was dismal. Again, the PF demonstrated limited knowledge regarding the airplane’s automation. It is little wonder he unknowingly deactivated the planes automatic speed control. He did not understand how the Boeing 777 A/P and A/T system work in tandem to control the airplanes speed during the FLCH –SPD mode. Again it is clear that he was not conversant with how the A/T auto engagement feature works.


According to NTSB, it was found out that the PF did not fully adhere to Asiana’s standard operating procedures about the airplane call outs. The whole crew was found to fail to adhere to the Asiana’s sops regarding selections and callouts consistently. They consistently breached the mentioned sops during the auto-flight system MCP. The lack of adherence is demonstrated where the PF was unable to call out a flight level change upon selecting the FLCH-SPD mode. Consequently, the PM failed to notice that the FLCH-SPD state was changed. It is likely that he was more concerned with changing the flap settings during the time. Again, when the flight was 500 AGL despite it having an unstabilized approach the flight continued descending. The airspeed indication was 5 knots more than the target speed approach. As a result, the PAPI indication signaled four red colors indicating a turnaround. It is herein where the difficulties arose. The PM mentioned that both the airspeed and the airplane position below the glide path being too low. This was misunderstood by the PF as a reference to the glide path which he responded by pulling the control panel. He was under the impression that A/T system would adjust efficiently to maintain the targeted airspeed. Subsequently, the airspeed decreased even more. By the time the PM was calling out for a go-around, the plane was more unstabilized. Consequently, in this unstabilized state, the plane was unable to manage a successful go around, and its main landing gear and the lower fuselage struck the nearby seawall leading to the accident.

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Automation Usage

As earlier mentioned the PF indicted inadequate understanding of the intricacies of the autopilot operation. According to his recorded statement, he thought that the A/T system would continue operating and maintain the flights, airspeed despite a manual changing of the thrust levers of the plane during the FLCH-SPD mode. Surprisingly the same was reported by other Asiana’s pilots when interviewed. This shows the lack of knowledge among the company’s pilots about the flights. However, they would be forgiven due to the complexities associated with the autopilot system of the Boeing 777 system. In fact, one of the recommendations of the NTSB was for Boeing to reduce the complexity of its autopilot system, as majorities of the pilots were not conversant with its operation methods. Again, the flight was equipped with a low-speed alerting system to alert the flight crew on low speed during the cruise. This is mainly to help the team in avoiding Stall during the journey. However, the low-speed system was unable to alert the crew of the low speeds during the planes landing.


In conclusion, it is worth mentioning that the weather during the accident was conducive to efficient landing. According to the NTSB report, the weather at the time was characterized by light winds which overall would not have hindered the successful taking off the plane. The main reason behind the accident was the lack of adequate communication between the PM and the PF.The PF misinterpreted some of the PF callouts demonstrating the lack of coordination between the two. The complex nature of the flight autopilot system was also a hindrance to the flights overall take off. Fatigue on the part of the pilots was also cited as one of the reasons behind the accident (Harris, 2011). Having shown the accident was a result of the misuse of the autopilot system and inadequate monitoring of the flight instruments, clearly demonstrates the caveats of the flight’s automation system. In future pilots should be trained on both the manual and automatic handling of the plane to prevent such incidences.


Harris, D. (2011). Human performance on the flight deck. Ashgate Publishing, Ltd..

National Transportation Safety Board. (2013, July 6). The crash of Asiana Flight 214 Accident Report Summary. Retrieved February 19, 2018, from

Surges, C. S. (2014). The Science of a Plane Crash. Cherry Lake.

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