Advanced Aerodynamics: Asiana Airlines Flight 214 Accident Analysis

This report provides a comprehensive analysis of the Asiana Airlines Flight 214 accident, focusing on the causes, consequences, and recommendations for flight safety improvement. The introduction highlights the nature of aviation accidents, emphasizing the importance of safety measures. The report delves into the causes of the accident, particularly the role of pilot fatigue, including discussions on its psychological and physical aspects. It examines the NTSB's findings on pilot sleep patterns and the impact of fatigue on performance. The consequences of the accident, as reported by the NTSB, are outlined, including the number of casualties and aircraft damage. The primary and secondary causes are identified, with fatigue as the main factor and flight scheduling as a contributing element. A detailed chain of events leading to the accident is presented, emphasizing crew mismanagement, automation issues, and communication breakdowns. The report concludes with recommendations for enhancing flight safety, such as the implementation of Fatigue Risk Management Systems (FRMS), improved pilot training, and adherence to standard operating procedures. References to relevant sources are also included.

Advanced Aerodynamics

Table of Contents
Introduction..............................................................................................................................................3
Causes of event.........................................................................................................................................3
Consequences of the event.......................................................................................................................4
Primary and secondary causes of the accident.........................................................................................5
Chain of events that led to eventual accident...........................................................................................5
Recommendations for flight safety improvement....................................................................................7
References................................................................................................................................................8

Introduction
An air crash is the aviation mishap and accident (He & Li, 2011). A lot of the airlines
like helicopter, airplanes, jet planes and air balloons are designed to make sure that there is a
huge level of safety provided to passengers. Still, the aviation accidents take place and are
harmful to lives. It is unavoidable accident that can’t be predicted. It brings the tragic loss of
life. These aviation accidents can take place due to various key factors such as human error,
bad climatic conditions, and failure of engine, aviation element breakdown or breakdown of
the device. Apart from that, other usual factors that lead to the aviation accidents are the
errors of traffic control system, bird strikes, fire in the cabin, and defects in design, sabotage,
inadequate fuelling, high jacking and lighting issues. The case of an Asiana Airlines Flight
214 Boeing with number 777-200ER, HL7742 San Francisco, California, has been
considered to understand the skills that are required to be taught to those who seek to be a
part of the piloting career.
Causes of event
The National Transportation Safety Board (NTSB) estimated numerous standards
concerning fatigue like the last sleep and its quality, circadian aspects along with the time
period awake etc. It was concluded that the main cause of the accident was that during that
accident all the three pilots had been going through any kind of fatigue. This might be a
disturbance in the circadian regularity and having less or broken sleep then usual sleep.
Therefore, the performances of all the pilots were spoiled at the time of accident.
Fatigue is a human aspect which is not easy to be defined but when we look at others
we can identify this feeling. It can be a psychological/ mental or physical kind of fatigue. By
psychological/ mental fatigue there can be a drop seen in the cognitive behaviour. It reduces
the capacity to carry out any task in a secure an effective way. On the other hand, a physical

fatigue happens when the muscles are tired and the person isn't able to uphold optimal
physical performance. Fatigue can be a transitory situation because of inadequate sleep
however it can bring severe physical and psychological disability. Fatigue is usually confused
with the terms like sleepiness or tiredness. Although sleepiness and fatigue are interrelated
still they cannot be termed as synonyms.
As per the International civil aviation organisation, fatigue can be defined as- “a
physiological condition of a decreased emotional or physical performance capacity which is
caused due to inadequate sleep or extensive restlessness, circadian stage or excessive
workload which can spoil the crewmember’s attentiveness and capacity to safely carry out
the task/ duties” (ICAO, 2013).
For assessing the cause of the accident the number of hours of sleep of the pilot
flying, pilot monitoring and the observer had been evaluated with respect to their normal
sleep hours. As per the reports by NTSB, the pilot who was flying the aircraft had got less
hours of sleep then his normal in the 24 hours prior to the mishap. So it can be seen that the
main cause of the mishap was nonconsolidated sleep which is not equally restorative to the
consolidated one. Also even though the pilot monitoring and the observer reported that they
had adequate sleep in the previous 24 hours however that sleep was segmented which
reduced the restorative value.
One more cause for the accident was that all these three people were facing the issue
of fatigue because the time of accident was among their normal sleeping hours. At this point
of time their physiological attentiveness was at its lowest.
Consequences of the event
As per the NTSB’s reports issued:
- 3 out of the 291 passengers were seriously wounded,

- 40 commuters got severe wounds.
The Boeing was damaged by a post-collision flames and collision services.
Primary and secondary causes of the accident
Even though Asiana had undertaken different steps for preventing and mitigating
fatigue, still the primary cause of this accident was fatigue. The steps involved in training the
pilots and the accident crews on the cause-and-effect of fatigue (Williams, 2017). In this
training the strategies were also been shared for minimisation of fatigue and the flight crew
was told about the rest activities. There were provision of rotating the primary and relieve
pilots in order that pilots were always attentive. Even though there was an Observer also
aside for the monitor so that the primary flight crews activities were recorded in the
monitoring capacity was improved. Beyond all these measures being undertaken, the timings
of this flight had huge chances of causing fatigue. So it can be said that primary cause of this
accident was the fatigue and the secondary cause had been timing or scheduling of the flight.
Chain of events that led to eventual accident
There was flight crew's mismanagement as from the beginning there had been a phase
of stress that reduced the capacity of pilot to monitor the flying pilot’s activities. This was
when there was an unintentional deactivation of automatic air speed control system. Even
though when the plane was at 200 feet One or two crewmembers got to know of the lower
airspeed and situation however no action was taken and tell the aircraft went below hundred
feet. After this, the situation went beyond control. The flight crew was facing fatigue, which
led to the gradation of the activities while doing their work. There was even non-standardised
communication and coordination among the flying pilot and monetary pilot when they had to
make choices for controlling the AFDS (autopilot flight director system) and A/T

(autothrottle) was there. There was a perplexity which brought degradation of their abilities to
deal with A/T and AFDS.
So there was a series of mistakes like inadequacy of Crew monitoring of air speed
signals which was caused due to fatigue, dependency on automation, higher workload, and
high expectancy. Even after all this there had been delayed start-up of recovery steps by the
flying pilot and the monitoring pilot once they got to know off the low-power and low
airspeed. All this happened due to mixture of surprise, non-standardised communication and
the perplexity of role & responsibility.
The NTSB found out that the possible cause for the mishap was set of events like:
- The aircraft’s crew’s mismanagement led to the aircraft crash,
- the pilot who was flying unintended deactivated the automatic year speeding control
system,
- Flight crew members were not adequately monitoring the airspeed,
- Flight crew members also delayed the caring out of their job once they came to know of
the aircraft being under the acceptable gliding part and air speed limits.
So all in all, it can be said that the events which led to the mishap were complications of
autothrottle and auto pilot flying director schemes that were not sufficiently explained in
Boeing's documents and Asiana's pilot guidance, which led to the chances of inaccurate
mode. Also there was non-standardised communication and coordination among the crew
members which was in terms of the utilisation of autothrottle and auto pilot flight systems.
The pilot who was flying was not adequately trained towards the planning and getting out of
visual systems. The monitoring pilot or the instructor was also not adequately supervising the
pilot who was flying the aircraft. Ultimately all these factors were combined with the crew's
fatigue which downgraded the performances.

Recommendations for flight safety improvement
As per NTSB it is recommended that necessary steps are undertaken for handling
such situations however it is also admitted that it is highly complicated to fully remove the
fatigue of crew members while operating for long distant flights. Still this task is not
impossible and the suggestions are made that airlines can gather the information regarding
the pilot fatigue while carrying out the operations. By use of this data gathered little
adjustments can be made in scheduling and different aspects, which can help in maximisation
of the rest of the pilots and minimisation of happening of fatigue while there is work
pressure. This kind of approach is recommended by ICAO instructions booklets where in the
topic of fatigue risk management system (FRMS) is explained. During this mishap, Asiana
was at the initial phase of planning and developing and FRMS. As per the report issued by
NTSB, if FRMS is created and executed one time then it can definitely lead to reduction of
flight crew members' fatigue. Since this airline has trans-meridian flights and long durational
flights therefore it is recommended that the development of FRMS is expedited. It is also
recommended that the flight crew members follow the operator SOPs and go through the
proper training so that there is improvement in their communication, and does leading to
mitigation of impacts of a take on long durational flights. Therefore the improvements in all
of these aspects are suggested.

References
He, G., & Li, X. (2011). Numerical Simulation of Loitering Aircraft Aerodynamics in Low
Speed Flight. Advanced Materials Research, 204-210, 139-143.
International Civil Aviation Organization: Proposals Concerning Unlawful Interference
Against International Civil Aviation. (2013). International Legal Materials, 9(06),
1183-1217.
Williams, M. (2017). Boeing 777 from Seoul crashes on landing at San Francisco
airport. The Guardian. Retrieved 23 August 2017, from