On the sixth of June, 2013, Asiana Airlines Flight 214 departed Incheon International Airport near the capital city of Seoul, South Korea. Its destination: San Francisco International Airport. Unfortunately for the crew and the passengers of Flight 214, that destination wouldn’t come without incident. On final approach, the aircraft would come up just short of the runway, the landing gear impacting the seawall, causing the Boeing 777 to tumble and the tail section to break off after impact.
For the crew of Flight 214, this would prove to be the ultimate test and, for the total 307 souls on board, the most poignant lesson in the risks posed by misunderstood technologies, the dangers of unintuitive systems operated by fallible human beings, and the extreme costs incurred in matters of human life. In terms of numbers, for Flight 214 that cost begins at the three lives lost, the 187 who were injured, and all who suffered and who carry the trauma of the incident.
As is the case in virtually all aviation accidents, the lessons extend beyond the cabin and the cockpit. Where the accidents are attributable to disorientation, human error, breakdowns in communication, crew or information mismanagement, structural or mechanical failure, they each afford us invaluable insight into the limits of both technology and human performance, and they each demonstrate the special need for precision and exactness where there is simply no room for error; where the costs of failure are immeasurable and the losses irrecoverable. In the case of Flight 214, it is a lesson about culture: that culture in Asian aviation (and society) which places an abundance of faith in the wisdom of automation.
The case of Asiana Airlines Flight 214 demonstrates the delicate balance required for the safety of flight: that balance between improvements in technology and the new training requirements that these changes necessitate.
In its final investigative report, the US National Transportation Safety Board (NTSB) highlighted just these issues, determining that the crew had relied too heavily on automation that they did not understand; that they had unintentionally disabled the plane's auto-throttle during the approach; and that they had failed to initiate a go-around when it was clear that the airplane was outside the allowed airspeed and altitude tolerances.
The NTSB's report described the complexities of the autopilot and auto-throttle systems that had confounded the pilots, concluding that these systems were not adequately explained in either Boeing's manuals or Asiana Airline's pilot training. The report noted that all of these failures were likely compounded by the effects of fatigue.
The NTSB recommended that Boeing develop enhanced training on automation modes to prevent confusion about when certain modes are activated. It also recommended that Asiana Airlines emphasize in its pilot training the need to adhere to standard operating procedures regarding autopilot use and the need for call-outs in the event of automation mode changes. The NTSB also recommended that the airline require its pilots to do more manual flying, both in training and in daily operations.
Ultimately, the case of Asiana Airlines Flight 214 is a case of people becoming too reliant on systems with inadequate understanding of their limitations and their inner-workings, and thus the implications of any changes or modifications entered into the system. It is a case of people lacking the skills to complete the most basic of tasks and failing to recognize the most basic of dangers; tasks further complicated and dangers exacerbated by that general lack of understanding.
Ultimately, the case of Asiana Airlines Flight 214 demonstrates the risks posed by that combination of ignorance, hollow faith, and governing systems dishonest about the human condition. It shows just how one's understanding of complex systems can save lives and prevent disaster, or alternatively how misunderstanding, blind faith and ignorance can bring death, devastation and despair.
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