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Asiana 214 and the Critical Importance of CRM

Human Factors | September 30, 2014

Author: Gary Allen


On July 16, 2013, Asiana Airlines Flight 214 struck the seawall on approach to San Francisco’s International Airport while attempting to land in day VFR conditions on Runway 28L. VREF for the approach was calculated at 137 knots. Through a series of errors and misunderstandings by the flight crew, as cited in the NTSB hearing on June 24, 2014, the airspeed was allowed to decay to 34 knots under VREF to 103 knots, at which point the B777 was too low and too slow to attempt to go around.

The first question that comes to mind is, how can something like this occur in day VFR conditions in an airplane with a safety record like the B777?

This accident highlights the importance of proper and thorough CRM/TEM training. The following were some of the human factors highlighted by the NTSB as contributing to the accident:

  • Flight Path Management (technical proficiency & workload management)
  • Understanding of Automation (technical proficiency)
  • Communication and Coordination (communication & teamwork)
  • Monitoring (technical proficiency & workload management)
  • Go-Around Decision-Making (communication/workload management/technical proficiency)

The benefits of a crew well trained in CRM/TEM are well-documented. I have been fortunate that I have been able to personally witness the metamorphosis of CRM/TEM in my 31 years as a major airline pilot, my many years as a designated examiner authoring training programs, and as an OE instructor. CRM/TEM has made my job easier, and ultimately much safer for all involved.

Our industry has never been safer, and proper CRM/TEM training and recurrent training is the key to maintaining this high standard and avoiding the errors that occurred on Asiana 214.

Gary Allen is a founding partner in CRM LLC, a company specializing in CRM/TEM training for all critical outcome high reliability professions. He is currently an A330 Captain for a major international airline with 31 years seniority, logging more than 28,000 hours. He has an extensive background as an FAA-designated examiner on the 747, OE and simulator instructor, and in AQP program development and Flight Standards.

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