WASHINGTON — A Boeing 777 arriving in San Francisco on a clear, bright day hit the seawall just short of the runway because the crew did not understand crucial details of the cockpit automation, the National Transportation Safety Board said Tuesday, recommending changes in training and flight manuals and in the airplane itself.
"It was the pilots, it was the automation, it was the intersection between the pilots and the automation," the acting chairman of the board, Christopher Hart, said.
The pilots missed multiple cues at the late stages of the approach that they had made serious errors, investigators said, beginning with confusion about the auto-throttle, which they were relying on to keep the plane at a safe minimum speed. But the pilot had inadvertently turned off the auto-throttle by giving multiple instructions to the autopilot, and he failed to follow airline procedures in the sequence of instructions and did not announce what he was doing, which might have tipped off the two other pilots. No one was keeping track of the airspeed.
The crash on July 6 of Asiana Airlines Flight 214 killed three people, making it the first fatal airliner disaster in the United States in more than four years. The accident raised questions about whether automation, which has generally helped safety and is essential to long-range flights, was contributing to a decline in basic pilot skills.
The board urged numerous changes, including the installation of a more effective automatic warning system in planes.
Boeing said it "respectfully disagrees with the NTSB's statement that the 777's auto-flight system contributed to this accident."