WASHINGTON (CBS SF) -- The crash of Asiana Airlines Flight 214 at San Francisco International Airport last July was a result of an over-reliance on automated systems in the plane, National Transportation Safety Board officials said at a hearing Tuesday in Washington, D.C.
The July 6 crash of the Boeing 777 injured more than 180 people and killed two young schoolgirls from China. A third girl was also killed when she was run over by San Francisco fire trucks responding to the scene, according to NTSB officials.
The flight crew's incomplete understanding of the plane's autothrottle systems, an over-reliance on automated systems in landing, poor training, miscommunication and fatigue were contributing factors to the problems in the plane's descent, according to the NTSB's findings, which were read Tuesday by acting chairman Christopher Hart.
The board made seven recommendations to prevent such a crash from happening again, including better training in automated systems by the Federal Aviation Administration and the airline, a review of the automated systems designed by Boeing for intuitiveness and potential new safety features, and for the airline to encourage pilots to manually land planes for better alertness and reaction time.
NTSB acting chairman Christopher Hart said the Asiana crash was caused by a flight crew that "over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway."
NTSB operations group chairman Roger Cox said, "Although the pilot flying was experienced, he lacked critical manual flying skills."
Federal Investigators Examine Pilots' Actions In Asiana Flight 214 Crash
Reports released by the NTSB at a fact-finding hearing in December revealed that pilot Lee Kang Kuk was being trained in flying Boeing 777s and that there was confusion over whether he or instructor Lee Jung Min should have called off the landing when it was determined the plane was flying too low and slow.
That miscommunication led to the pilots calling far too late for a "go-around" to re-attempt the landing before the plane's tail hit the seawall.
NTSB officials today released a nearly four-minute animation sequence of the events that led to the crash.
Tuesday's hearing also touched on the death of 16-year-old Ye Meng Yuan, one of two girls who was ejected from the plane in the crash and was run over by two fire trucks in front of its left wing.
An autopsy by the San Mateo County coroner's office determined that Yuan was killed by the fire trucks rather than the impact from the crash.
NTSB investigator Jason Fedok said firefighters thought that Yuan was already dead when they saw her by the wing and there was "a short window of opportunity for firefighters to perform triage and verify visual assessments, but they did not do so."
Fedok said the girl being run over was part of "numerous problems with communication during the emergency response."
"Something happened that never should have," Hart said of the girl's death.
While the board did recommend improving communication in first responders' triage processes, particularly since difficulties communicating in such a chaotic scene can be anticipated, it also credited the fire department's aggressive response with saving the lives of five people who were trapped inside the burning aircraft.
Fedok said that Yuan and another 16-year-old girl who died in the crash were not wearing seat belts during the landing and likely would have survived if they were secured in their seats.
The third girl who died, a 15-year-old classmate of the other two girls, was not ejected from the plane but was struck in the head by a door that was torn from its frame by the impact of the crash, Fedok said. She succumbed to her injuries at San Francisco General Hospital six days after the crash.
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