Review of NTSB Asiana flight 214 investigative hearing

On 11 December 2013, the NTSB conducted a day-long investigative hearing into the 6 July 2013 crash of Asiana flight 214 in San Francisco, featuring public testimony from representatives of Boeing, Asiana Airlines, and other organizations directly involved in the accident and the subsequent investigation. While the NTSB had previously released to the public substantial amounts of information about the accident, there was quite a bit more new material presented at the hearing.

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For a summary of the hearing, listen to the Al Jazeera America interview featuring their transportation contributor Dr. Todd Curtis.

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The amount of information presented at the hearing was noteworthy, as was the way that it was released. Like it has since the day of the accident, the NTSB has been very innovative in the way that it has used the Internet to get information very quickly to the public. This article describes some of the information presented in the hearing, and also points out some of the areas where the information released could be incomplete or misleading.

The purpose of the investigative hearing
The NTSB holds public hearings during major accident investigations for many reasons, among the most important is making the public aware of the progress of the investigation, and to focus attention on the key areas of the investigation. While the key parties involved in the investigation, most notably Boeing and Asiana airlines, provided testimony and answered detailed questions from NTSB Board members, they have all been closely involved with the investigation from the beginning, and have likely already provided the same information to the investigators.

The public testimony is more of an opportunity for the media and the general public, including accident victims and their families, to learn additional details of the investigation and to get an idea of where the investigation is heading.

What the NTSB discussed
The NTSB investigative hearing focused on five areas:

1. Boeing 777 flight deck design concepts and characteristics
2. Asiana pilot training on Boeing 777 automated systems and visual approach procedures
3. Effects and influence of automation on human performance in the accident sequence
4. Emergency response
5. Airplane cabin crashworthiness and occupant protection.

The investigation is far from complete
The investigative hearing is only part of the accident investigation process, focusing on the factual aspects of what happened in the accident and the initial emergency response to the crash, as well as factors that may have played a role in circumstances that led up to the accident or that affected the emergency response.

Hearing testimony provided insights into the "what happened" kind of questions being asked by the NTSB, such as what was the sequence of events that occurred immediately before and after the accident, as well as insights into "why it happened" questions such as the kind of training provided to the flight crew on the accident aircraft. The latter parts of the investigation focuses on answering "why it happened."

Other "why it happened" type of questions may address issues or explain circumstances that happened days, months, or even years before the accident, and that may have led to the situations that allowed the accident to occur and that may have made deaths and injuries either more or less likely once the accident occurred. The hearing didn't fully answer all of the "what happened" and "why it happened" questions. Complete answers to these questions, and well as recommendations for changes and improvements, will likely not happen until the final report is published.

These recommendations, which are answers to "what should be done" questions, typically, but not always, get answered at the time the final report is published because much of the analysis of the accident happens after the NTSB and their investigative partners have had an opportunity to sort through information from a variety of sources. NTSB final reports have a similar organization, and typically have three sections; Findings, Probable Cause, and Recommendations, that are associated with the three kinds of questions mentioned earlier. The "Findings" section would answer the "what happened" questions, the "Probable Cause" section would answer the "why it happened" questions, and the "Recommendations" section would address the "what should be done" questions.

Key implied "what happened" questions
While the investigation is not complete, and other factual information may come to light later, the testimony provided in the hearing implied that the following scenario led to the crash:

• Although the glideslope portion of the landing runway's instrument landing system was not operational, and the crew was vectored for a visual approach to the landing runway, the Asiana crew decided to used both the autothrottle and autopilot during their landing.
• The autothrottle was being used to control airspeed, and the autopilot was being used to control the flight path.
• During the latter part of the landing attempt, the crew disconnected the autopilot and manually adjusted the throttles, and this put the autothrottle in a mode where it was no longer controlling airspeed.
• The crew continued the landing attempt, and the airspeed was decreasing, but did not take actions to increase the airspeed soon enough to avoid crashing short of the runway.

Key unanswered "why it happened" questions
Critical "why it happened" questions that were hinted at in the hearing, but not yet answered, include the following:

• Why didn't the crew take corrective action sooner in the landing sequence?
• Why did the crew use the autopilot and other cockpit automation in ways not recommended by Boeing?
• Why did the Boeing training organization make certain assumptions about how much airline pilots know about how to use cockpit automation?

How this investigation was different
The Asiana crash was a high profile event, not only in the US, but also in South Korea, where Asiana is based, and China, which had a significant number of its citizens on the flight. The NTSB went to great lengths to accommodate the media interest in this investigation; as well as the public interest in the US, South Korea, and China; by doing the following:

• Providing a streaming online video stream of the entire hearing,
• Providing a real-time translation of the hearing in Mandarin Chinese and Korean,
• Providing a simultaneous transcript in English of the proceedings,
• Using social media, primarily Twitter, Flickr, and YouTube, to provide related photos,videos, and links to additional material.

While the NTSB has historically provided information freely to the public, until the advent of the Internet, it was very difficult for individuals to get access to the final reports or the supporting data behind their investigations. In recent years, and especially during the Asiana investigation, the NTSB has aggressively used social media like Twitter, Flickr, and YouTube to provide more information than ever before, with even fewer delays. While this level of openness has caused some friction in the past between NTSB and other aviation organizations, the amount and types of information provided by the NTSB during this hearing was consistent with their recent communications policies.

Issues with the NTSB's hearing information
While providing a live webcast, a real-time transcript, and simultaneous translations into other languages were very positive actions with respect to providing information, it is important to recognize that there are potential issues with this information that may limit its usefulness or lead to misinterpretations by the media or the public:

• The transcript of the Asiana hearing was not completely accurate, so if someone requires an accurate transcription, that portion of that transcript should be compared to the appropriate portion of the video.
• The webcast video of the hearing will be archived, but it is not clear if the original, somewhat flawed, transcript will also be archived, if there will be a revised transcript archived, or if the NTSB will not archive any transcript.
• The participants in the hearing were provided with simultaneous translations of all the statements made during the hearing, and it is not clear if those translations were completely accurate. Some of the technical information provided in the hearing was both complex and subtle, and may not be completely understood even if the speaker and listener shared the same language. Some of the spoken testimony has accompanying presentation slides that would help understanding, and may be necessary to view those to make sense of the spoken testimony or the information in the transcript.

Dr. Todd Curtis interviewed by Al Jazeera America
Dr. Todd Curtis, transportation contributor for Al Jazeera America, was interviewed by John Seigenthaler about some of the issues discussed during the NTSB hearing.
Listen to the interview

Key NTSB Asiana investigation resources
Asiana flight 214 investigation main page
Asiana flight 214 accident docket
Asiana flight 214 investigative hearing transcript (archived by AirSafeNews.com)

Key NTSB social media resources
NTSB webcast archives
NTSB YouTube channel
NTSB Flickr photos
NTSB Twitter stream
NTSB RSS feeds
NTSB email subscriptions

Related AirSafeNews.com articles

• AirSafeNews.com 13 July 2013 article summarizing final two NTSB briefings at SFO
• AirSafeNews.com 10 July 2013 article on the role of the autothrottle
• AirSafeNews.com 8 July 2013 article on early findings of the crash investigation
• Other Asiana plane crashes
• Other 777 plane crashes
• Accident details from Aviation Safety Network
• Wikipedia page on this accident

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Find out how to help Todd Curtis run the Boston Marathon at marathon.airsafe.com

NTSB has live webcast of Asiana 214 investigative hearing today

The NTSB's hearing on Asiana flight 214 began this morning and will end this evening. It is notable for its use of technology to get information quickly to the public. There is no only a live webcast, but also also a live written transcript in English combined with options for translations in Korean and Mandarin Chinese.

This hearing was originally scheduled to take place over two days, but the first day was cancelled due to weather in the Washington, DC area. The agenda was revised so that it could be completed today, and the hearing will run until about 8:00 p.m. This hearing will also be archived for several months, making it very easy for the media and especially the general public to come to their own conclusions about the information provided by witnesses.

Finding live comments on Twitter
If you are searching for recent comments on Twitter, helpful hashtags include #NTSB, #Asiana, and #777.

Resources
Asiana flight 214 NTSB investigative hearing information

Measure turbulence while you fly

If you fly regularly, you will routinely experience turbulence. Although it is routine, it can be worrisome to some air travelers who are already anxious flyers. Most of the time the amount of turbulence is very small, and although the flight crew may reassure passengers either before or after encountering turbulence, they don't provide passengers with any kind of objective measures for turbulence, and passengers had no easy way of finding out on their own.

That has all changed with the release of the new SOAR Fear of Flying smartphone app. Available in versions for iPhone, iPad, and for Android devices, the app includes a G-force meter that you can use to chart the amount of turbulence that you are personally experiencing. An example of this screen is below:

Get the app today!
The app is free, and can be downloaded by clicking the image below or by clicking here:

NTSB train crash investigation has lessons for future plane crash investigations

Normally, this site focuses on airline related safety and security events, but the NTSB investigation into the 1 December 2013 fatal derailment of a commuter train in New York is an exception because some of the recent developments in the investigation are quite relevant to how the NTSB would investigate future airline accidents.

The NTSB is best known for its investigations of airline accidents, but it also investigates accidents involving other modes of transportation, including rail accidents. NTSB Board Member Earl Weener, who is a former Boeing executive, is heading the investigation of the fatal 1 December 2013 crash of a Metro-North commuter train in New York, and part of that process includes involving relevant parties that provide technical expertise in support of the NTSB's investigation. During the early part of the investigation, the NTSB serves as the primary conduit of information to the media and the public on the progress of the investigation, and sticks primarily to factual information about the accident. Determination of probable causes, and the role of organizations and individuals in the accident typically happens much later in the investigation.

One of the parties invited to participate in this investigation was the Association of Commuter Rail Employees (ACRE), which represents Metro-North several categories of Metro-North employees. However, the NTSB abruptly removed ACRE from the investigation onm3 December 2013 after a representative of the union gave a series of briefings to the media where that representative discussed and interpreted information related to the ongoing investigation.

This is a very rare move for the NTSB, and one that underscores the importance that the NTSB places in adhering to its investigation process. If this had been an airliner accident investigation, the NTSB would have likely taken the same action. While news media organizations and other groups not directly involved in the investigation are free to speculate about the causes of an accident, parties that are part of the NTSB investigation don't have that option. There are many reasons for this, and perhaps the most obvious one is that publicly speculating about the causes of an accident is inappropriate before all of the relevant factual information about the accident has been analyzed.

Below is Earl Weener's NTSB briefing from 3 December 2013.

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SOAR Fear of Flying offers $100 discount
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No survivors from ERJ-190 crash in Namibia

29 November 2013; LAM ERJ-190AR; C9-EMC; flight 470; Bwabwata National Park, Namibia: The aircraft was on a scheduled international flight from Maputo, Mozambique, to Luanda, Angola, and crashed in northern Namibia near the borders of Botswana and Angola. All 27 passengers and six crew members were killed in the crash.

About the ERJ-190
This was the second ERJ-190 event involving passenger fatalities. The first was an August 2010 crash in China involving a Henan Airlines ERJ-190. 44 of the 96 occupants were killed. The ERJ-190 series, which includes the ERJ-195, first flew in 2004, and according the AirFleets.net, over 600 have been produced. The US airline with the largest fleet is JetBlue, with about 59 ERJ-190 aircraft.

About airline
LAM (LAM Mozambique Airlines) is the national airline of Mozambique, and currently has six remaining aircraft, including four 737s and two other ERJ-190s. The European Union bans all airlines from Mozambique, including LAM, from operating in the EU. The FAA, which provides safety ratings for national civil aviation authorities, have not provided a rating for Mozambique because it has been at least four years since any airline from that country has provided air transport service to the US, have had any code share arrangements with US air carriers, or have had any significant interaction with the FAA.

Additional resources
ERJ crashes

No survivors from 737-500 crash in Russia

17 November 2013; Tartarstan Aircompany 737-500; VQ-BBN; flight 383; Kazan, Russia: The aircraft was on a scheduled domestic flight from Moscow to Kazan, Russia, and crashed during a landing attempt shortly after 7 pm local time. Early reports indicated that it was at least the second landing attempt. All 44 passengers and six crew members were killed in the crash and subsequent fire. RT News has provided a profile of several young parents who were among the crash victims.

Below is a security camera video that shows the aircraft in a high-angle dive shortly before impact:

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About the 737
This was the 73rd fatal event involving the 737, and the fourth involving the 737-500 series. The first 737 aircraft began commercial operations in 1968, and the first of the 737-500 series began service in 1990.

The first fatal event for the 737 was in 1972, and the previous fatal crash was in April 2012. There have been four prior 737-500 crashes that resulted in serious or fatal passenger injuries:

1. 26 July 1993; Asiana Airlines 737-500; near Mokpo, Korea: The aircraft struck high ground in poor weather about 4 km from the runway while it was making its third attempt at a landing. Four of the six crew members and 64 of the 104 passengers were killed.

2. 7 May 2002; EgyptAir 737-500; near Tunis, Tunisia: The aircraft crashed about 6 km (3.8 mi) from the airport after a flight from Cairo. The aircraft was reportedly making a second approach for landing when it crashed into high ground during a period of reduced visibility due to fog and sandstorms. Three of the six crew members and 11 of the 56 passengers were killed.

3. 14 September 2008; Aeroflot-Nord 737-500; Flight 821; near Perm, Russia: The aircraft was on a scheduled domestic flight from Moscow to Perm, Russia. Contact with the aircraft was lost shortly before landing when the aircraft was about 3,600 feet, or about 1100 meters, above the ground. The aircraft was completely destroyed in the crash, coming down outside of the city of Perm and near the tracks of the Trans-Siberian Railway. All 82 passengers and six crew members were killed in the crash. There were seven children, including one infant, among the passengers.

4. 20 December 2008; Continental Airlines 737-500; Flight 1404; Denver, CO: The aircraft, which was on a scheduled domestic flight from Denver, CO to Intercontinental Airport in Houston, TX, departed the runway during takeoff and skidded across a taxiway and a service road before coming to rest in a ravine several hundred yards from the runway. The aircraft sustained significant damage, including a post crash fire, separation of one engine and separated and collapsed landing gear. There were about 38 injuries among the 110 passengers and five crew members, including two passengers who were seriously injured.

Additional resources
737 crashes
Crashes in the former Soviet Union

Lessons learned and insights from the LAX attack

On 1 November 2013, 23-year-old Paul Anthony Ciancia allegedly used an M&P-15 assault rifle to attack TSA personnel and others at Terminal 3 at LAX. Ciancia, who was not a ticketed passenger, is accused of shooting and killing one TSA security officer and wounding two other TSA officers and one passenger.

According to the FBI's charging document, Ciancia took his weapon out of a bag, and fired at a TSA security officer at point-blank range. Ciancia went up an escalator toward the security screening area, but returned to his first victim to shoot him a second time. This was the TSA officer who killed by Ciancia. The alleged gunman later shot two other TSA officers and a passenger before airport police confronted him inside the terminal, shot him several times, and took him into custody.

Key questions about the attack
The news media an the general public had many questions about the attack, how it could happen, and what could be done to prevent similar attacks in the future. Some of the common questions, and AirSafe.com's responses, are below:

• How could someone get a gun into an airport? - While only authorized persons are allowed to bring weapons onto aircraft or even past the TSA security screening areas, the rules are very different in other parts of the airport. Local laws control what firearms are allowed to be carried in the non-secure areas of the airport, including the ticket counter areas where passengers take their checked luggage. In fact, passengers who want to travel with their firearms have to bring them into the non-secure areas of the terminal and have them inspected before the airline will allow it to be shipped as checked luggage.

• How could the gunman get past the security checkpoint? - There is typically a significant security presence in the TSA screening areas, and usually include a combination of TSA officers, airport police, and other security and law enforcement personnel. The investigative authorities have not release all the details of the attack, and it is not clear what security or law enforcement assets were available to keep the gunman from gaining entrance to the secure area of Terminal 3.

• How can anyone get that close to a screening area without a ticket? - Airports in the US are freely open to the public, and with rare exceptions like a heightened security alert, there is no screening of cars arriving at the airport or of people walking around the non-secure part of the terminal.

• Do TSA officers have guns? - TSA officers do not have law enforcement powers, and are not armed. They rely on local police or other law enforcement organizations to provide armed security.

• Were there police on duty at the Terminal 3 checkpoint? - The investigating authorities (led by the FBI) have not yet stated where law enforcement officers were located at the time of the shooting.

• Did the TSA or the government have any warning of a possible attack? - Neither the FBI, the TSA, or any part of the federal government has made any statement about what they new prior to the attack. Since Ciancia was not a ticketed passenger, there would have been little or no reason for for any federal agency to investigate him. However, the Los Angeles police department had been contacted by Ciancia's family, who had been concerned about his well-being. Police had reportedly tried to contact Ciancia in the morning on the day of the attack at LAX.

• Are other airports vulnerable to this kind of attack? - The security procedures in place at LAX are similar to what would be found at every US airport. While every airport has the same vulnerabilities as LAX, in order for an attack to succeed, there has to be an attempt either by a group or an individual. Since 9/11, there have been two attacks of this type in the US, both at LAX, and both involving individual attackers. In both cases, security or law enforcement assets at the airport quickly addressed the situation shortly after the attacks began.

• What can be done to keep this from happening again? - Many things can be done, and in the short term there may be an increased presence of police in or near airport screening areas. However, it is unclear if there will be any permanent changes in policies and procedures of the TSA, of airport police forces, or of airports. Major changes, if they occur, will likely not happen for several months.

This was not the first LAX attack
Coincidentally, the last time there was a similar attack at a US airport was also at LAX, at the terminal adjacent to the site of the attack on November 1st. On 4 July 2002, a gunman staged an attack in the area of the El Al ticket counter, and shot several people before El Al security personnel were able to subdue the attacker and shoot him to death. Two people shot by the gunman, an El Al employee and a passenger, were killed.

Responding to an active shooter situation
The Houston Police Department produced the following video with advice on how to survive an active shooter event. While it depicts an attack in an office environment, it offers insights that could be used to deal with a similar unexpected attack in other locations, including an airport terminal.

Were you a witness to what happened at LAX?
If you were at LAX the day of the shooting, you could help the FBI investigate this crime. The FBI is asking anyone with information to submit it at laxshootingtips.fbi.gov. That site is for submission of audio, video, photos, and general information relating to the shooting at Los Angeles International Airport (LAX) on Friday, November 1. No piece of information or detail is too small. You can also call the FBI Los Angeles tip line at (888) 226-8443.

Additional information
FBI charging document for Ciancia
FBI warrant for Ciancia's phone