Original subtitles

Computer: Terrain. Terrain. Pull up.

Narrator: A final approach goes horribly wrong.

Man: Just wondering how it's gonna end.

Narrator: The dramatic rescue in San Francisco

is caught on camera.

Man: They used the terms "mass casualty event.".

Narrator: The search for a cause...

Man: Bingo!

Narrator: ...divides air safety experts.

Man: The worst mode possible!

Man: I disagree.

Narrator: Was it the pilots, the plane,

or something else that doomed Asiana flight 214?

Man: The hard part is to say

which one is the straw that broke the camel's back?

Flight attendant: Ladies and gentlemen,

we are starting our approach.

Pilot: We lost both engines!

Flight attendant: Put the mask over your nose.

Emergency descent.

Pilot: Mayday, mayday.

Flight attendant: Brace for impact!

Controller: I think I lost one.

Man: Investigation starting into this tragedy...

Man: He's gonna crash!

Lee Kang Kuk: Ladies and gentlemen,

this is your captain speaking.

We hope you had a pleasant flight.

We'll be on the ground in about 30 minutes.

Enjoy your stay in San Francisco and hope to see you again soon.

Narrator: Asiana flight 214 is nearing the end

of an overnight flight from Seoul, Korea, to San Francisco.

Ben levy is a frequent flyer returning home.

Ben levy: I fly pretty often for business or visiting my family.

I'm originally from France,

and so, you know, I fly long distance a lot.

I fly in and out of SFO a lot, so I know the airport very well.

Narrator: Many of the other 291 passengers are Chinese,

including a group of teenagers

on their way to summer camp in the united states.

Levy: I think they were all pretty excited about the trip.

I think they were all like, you know, having a good time

and excited to be in that plane and going to the U.S.

Kang Kuk: Is that the golden gate?

Narrator: Captain lee Kang Kuk takes in the sights

as he guides the plane toward the airport.

Lee Jung Min: Golden gate's over there.

That bridge goes to Oakland.

Kang Kuk: Ah. Okay.

Narrator: Lee Jung Min, also a captain,

is serving as first officer today.

Levy: Yeah, I remember it being a just gorgeous day,

as good as it can be.

No wind, beautiful, sunny day, not a single cloud in the sky.

Les Abend: The arrival into San Francisco

is a very scenic approach.

From the sierra mountains

all the way into the San Francisco bay area,

it's a very pretty arrival.

Jung Min: Runway in sight.

Controller: Asiana 214 heavy, turn left 3-1-0 degrees,

cleared visual approach.

Narrator: Controllers clear the crew

for their final turn to the runway.

Abend: It is a busy piece of airspace.

You do have to listen on the frequency

and you do have to anticipate

what the controller is going to give you.

In addition, experience really counts

flying into San Francisco.

Jung Min: Cleared visual approach, Asiana 214.

Kang Kuk: Okay.

Gear down, sir.

Jung Min: Gear down.

Abend: The way we put on the brakes in an airplane

is by putting our, our trailing edge flaps down

and our leading edge devices down, and even the gear.

That's our brake.

Narrator: They then enter an altitude to climb to

in case of a missed approach.

Kang Kuk: Missed approach, 3,000 feet.

Narrator: In the cabin,

the flight attendants prepare passengers for landing.

Controller: Asiana 214 heavy, runway 2-8 left, clear to land.

Jung Min: Landing checklist complete.

Clear to land.

On glide path.

Narrator: The pilots check a set of lights beside the runway

that can help guide them to a safe landing.

Kang Kuk: Check.

Narrator: The plane is less than a minute from the runway

when ben levy realizes something is wrong.

Levy: I remember noticing that there's a small pier

that extends out of the runway,

and I'm like, wow, we're very low.

And I dismissed the thought,

thinking, well, what can go wrong?

There's all the technology on board

to make sure that those guys don't, don't mess up.

Narrator: In the cockpit...

Jung Min: Speed!

Narrator: ...a crisis hits.

Computer: Terrain. Terrain. Pull up.

Jung Min: I've got control.

Oh, god! Go around!

Levy: In that fraction of a second,

I feel the thrust of the engine re-engaging full throttle.

Narrator: The captain pulls up the nose and tries to climb.

But it may be too late.

Levy: Hang on. Looks like we're not gonna make the runway.

At that point I'm thinking we're gonna hit the water.

Computer: Terrain. Terrain. Pull up.

Levy: The impact was very violent.

♪

Just wondering how it's gonna end,

how it's gonna stop and when it's gonna stop.

Jung Min: Hang on! Hang on!

Levy: So the plane comes to a rest.

And nothing moves.

And all you hear is moaning

from people that are hurt and injured.

Here. Here.

If you press hard it will stop the bleeding.

Narrator: In the cockpit, the pilots have survived,

but they have no idea how badly damaged their aircraft is.

The brutal impact has torn the tail off the body of the plane.

Jung Min: Control, come in.

It's Asiana 214.

Initiating evacuation checklist.

We need help out here.

Controller: Asiana 214 heavy,

emergency vehicles are responding.

Narrator: An engine is burning.

If fire spreads to the fuel tanks, the plane could explode.

Passengers need to find a way out, fast.

Levy: Let's see if we can open this door.

I remember just going for that big lever

on the right-hand side of this airplane

and just opening this door and was shocked at how easy it was.

Narrator: But getting down to the ground will not be easy.

Levy: I'm expecting at that point to see a slide open.

I had the whole, like, hey, you open the door,

the slide's gonna open, and there's no slide.

Whoa.

Okay.

Help each other.

Come on.

Narrator: Luckily, some crumpled pieces of the fuselage

have formed a makeshift set of stairs.

Ben levy stays by the door

to help the other passengers climb down.

Levy: Come on.

You know, in this whole disaster

they find that the fuselage actually had crumbled on itself,

almost provided like a step that became probably critical

for people, people to exit that plane.

Woman: Oh, my god. That's scary.

Narrator: Eyewitness video captures the dramatic scene

as hundreds of people flee the cabin from only a few exits.

The triple seven has eight exits.

Each is equipped with an emergency escape slide.

The slides are supposed to inflate automatically,

but only two have deployed properly.

Flight attendant: Someone?

Please help me!

Narrator: What's worse, two of the malfunctioning slides

have inflated inside the plane.

A flight attendant is trapped.

Flight attendant: I can't move.

If you pull, I can try.

No.

Get something sharp.

Ah! Ugh!

Bill bramble: She couldn't breathe under the slide.

Narrator: Bill bramble is an air emergency expert.

He understands the desperation the crew is facing.

Bramble: They were worried about her suffocating,

and so it was a very strong sense of urgency

to try and get her out.

Plus, there was a fire outside the fuselage as well.

So, yeah, it was a pretty serious situation.

Narrator: At San Francisco international airport,

runway 28-L is a disaster zone.

Fire crews battle to keep flames from consuming the fuselage

of Asiana flight 214.

Levy: Come on.

Get out.

Narrator: Inside the burning plane,

a flight attendant is still trapped.

Bramble: The slides are pretty tough.

You need a sharp, strong object

to be able to puncture the slide,

and a crash axe, do the trick.

♪

Narrator: With rescuers now on board to help the injured,

ben levy finally heads to safety.

Levy: I think in my head I was like,

I'm alive, it's incredible.

Narrator: He's soon sharing his harrowing story with the media.

Levy: In your head everything goes in slow motion.

You just don't believe it's happening.

You don't know if you're gonna be dead

at the end of the slow motion or not.

Woman: The entire trauma team has come together

as they would in a trauma,

although this is very large, multi-casualty incident.

Narrator: Nearly 50 people are seriously injured.

Six were thrown out of the back of the plane

when the tail broke off.

Two of them are dead,

including a young teenager run over by an emergency vehicle.

Man: The fire truck did go over the victim, that's a fact.

Now, what caused the death,

whether the victim was deceased before or as a result,

that is what we're trying to figure out.

Narrator: Like thousands of others,

investigators at the national transportation safety board

in Washington are riveted by the pictures.

Bill English: They used the terms "mass casualty event.".

We really didn't know what was going on at the time.

The first things I heard was an airplane cartwheeled,

mass casualties, and we knew it was a triple seven,

so it was going to be a very significant event.

Narrator: Senior investigator bill English

will lead the high profile investigation.

English: Everyone's on standby as of right now.

So the triple seven had been in service for about 20 years

at the time of this accident,

and this was the first fatal accident of a triple seven

in that entire time.

We knew we were going to be launching a very large team,

so we pulled out all the stops.

♪

Narrator: By the next morning,

there's a full team of investigators on site.

Their first impression is that the media reports must be wrong.

English: I had heard the phrase "The airplane cartwheeled.".

And the first photos that I saw

showed the airplane right side up,

wings still attached,

still looking pretty much like an airplane

sitting next to the runway.

So we thought that couldn't be true.

Narrator: When a plane cartwheels on touchdown,

the result is usually a catastrophic breakup

that leaves a long trail of debris.

That's what happened in 1989 in Sioux city, Iowa,

where a dc-10 cartwheeled off the runway, killing 111 people.

The wreckage from Asiana 214 looks nothing like Sioux city.

English can hardly believe the triple seven cartwheeled,

until he spots some telltale evidence.

English: We noticed the marks on the runway,

scrape marks and everything, looked strange.

It looked like the airplane twisted and turned around.

We thought did the airplane actually turn around?

And then we saw the video.

Narrator: Airport surveillance cameras leave no doubt

about flight 214's violent trajectory.

English: The surveillance video did show the airplane

literally pirouetting, lifting a good 30 degrees into the air,

spinning almost a full circle around before coming to rest.

Jung Min: Hang on!

Levy: It's just a miracle in so many ways,

the fact that this plane stayed in one piece,

the fact that the wing didn't break apart.

I mean, if we had landed back any other way,

it could have been terrible.

Narrator: Investigators must now determine

why the triple seven crashed short of the runway.

But they also face important questions

about the evacuation and rescue.

Jason Fedok: How did you end up out there?

Narrator: Investigator Jason Fedok will try

to figure out what happened to the passengers after the impact.

Fedok: Can you remember where you were sitting?

People who were actually involved in the accident

can give us a wealth of information

that we couldn't otherwise learn

about what happened inside the cabin.

Was she wearing her seat belt?

In this case, we talked to the seat mates

of one of the ejected passengers

who explained that she was not wearing her seat belt

at the time of the accident.

English: This investigation was almost

two investigations in one.

We broke it up into the part that got us to the seawall.

How did this airplane impact those rocks

and come to this accident?

After that was a whole other story to be told.

Narrator: The complex investigation

puts the entire team under enormous pressure.

There could be clues inside the ruined cockpit,

but toxic fumes and scorched debris make it too dangerous

to enter without protective gear.

Roger Cox: Okay. Here we go.

Narrator: For NTSB investigator Roger Cox,

the hunt for evidence is worth the risk.

Cox: It was a tricky accident site.

We had to be properly garbed up to make sure

that we weren't affected too much

by the dangerous wreckage that was there.

If you get out there right away

before anybody's had time to move anything around,

you can actually reconstruct what went on.

Narrator: Cox gathers the pilots' charts

and personal effects,

hoping to find clues about what they were doing

in the final stages of the flight.

Cox: That's everything I could find.

We removed every single document

and then made sure that we photographed every single page

of every single document

in order to see if any of it was of value.

Narrator: Many of the documents are in Korean.

They'll need to be translated

before they can be fully analyzed.

The crash zone, on the other hand,

immediately provides investigators

with some important details.

English: Where it impacted on the rocks of the seawall

pretty much tells us it was too low.

It landed well short of where it should have.

Narrator: The scenario reminds English

of another very similar accident.

English: One of the things we initially thought about

was a previous triple seven accident

that happened in London, England,

where both engines rolled back

and the crew didn't have any power at all on final approach.

Narrator: The triple seven has one of the best safety records

of any plane in the sky.

But in 2008 British airways flight 38 slammed to the ground

short of the runway at Heathrow airport

after losing power in both engines.

Investigators determined that ice in the fuel lines

had caused dual engine failure.

Is that what happened to Asiana 214?

A close look at the engines tells bill English

the answer is no.

He sees clear evidence that they were working normally.

English: There are certain signatures in the metal,

in the blades of the engine that show us

that they were developing power and hadn't failed.

Narrator: For now, English has no solid leads

to explain why a plane that seemed about to land safely

crashed just seconds from the runway.

English: We knew the weather was good,

winds were calm, visibility was good.

There was no distress call from the airplane

that we'd heard of, so there was nothing really obvious

as to why this would have occurred.

Narrator: Runway crews assess the damage

at San Francisco international airport

while investigators search for a lead

in the crash of Asiana 214.

Air traffic controllers provide some answers.

English: They could see it on radar,

and of course visually see it from the tower.

Controller: Visibility was ten miles, um, a few clouds,

not an issue.

Narrator: Controllers tell investigators

that it was a normal day,

except for the fact that some runway equipment

was not in operation.

Controller: And that runway's glide slope

was, was out of service.

Narrator: Electronic equipment installed on runways

can send signals to a plane's autopilot.

The signals can help guide the plane down at a precise angle.

But the main runway at the airport is under construction,

and the equipment is switched off.

It's a revealing discovery.

A combination of high traffic and compact runways

have earned San Francisco airport

a reputation for difficult landings.

To manage the high traffic,

controllers often ask pilots to come in fast and steep,

leaving lower altitudes open for departing planes to climb out.

Abend: Very often we are given

what we call the slam dunk approach,

where we're high and we have to get down quickly,

and it does create a little bit of a challenge.

Cox: Alright, so there's San Francisco airport.

Palo alto's down here, you know...

Narrator: Roger Cox knows firsthand

how challenging landing at San Francisco airport can be.

Cox: I could say from my own personal experience

flying in there many, many times

that it's very easy to get high and hot,

uh, and you have to really stay on top of the airplane.

Controller: Asiana 214 heavy,

runway 2-8 left, cleared to land.

Narrator: It all leads to some troubling questions.

Were the Asiana pilots flying into danger?

Did they face an extraordinary risk

at an airport notorious for difficult landings?

Cox: So he'd be coming in from this direction

straight across the bay.

Narrator: Roger Cox studies airport radar records.

He wants to know if controllers assigned Asiana flight 214

an approach that was too fast and steep to fly safely.

Kang Kuk: Clear to land.

Cox: There were some complaints initially from the operator

that this crew was being asked to do something

that was unreasonable,

so we wanted to spend quite a bit of time

looking at whether that was true.

Same instructions. Same approach.

No one else had a problem.

Narrator: Airport records reveal controllers

gave two other planes the same instructions

just before Asiana touched down.

Both landed safely.

Cox: You can't fault the controller.

They managed to land triple sevens safely

without any difficulty,

so although it is a somewhat challenging environment,

we found that nothing that ATC did really caused the accident.

Narrator: It's another dead end.

For now, what brought down Asiana 214 remains a mystery.

Along with the cause of the accident,

investigators are grappling with another troubling question.

Escape slides are engineered to withstand

the forces of aviation accidents.

Why did so many fail during the crash of flight 214?

English: Only two of them did what they were supposed to do.

Narrator: Six of the eight slides didn't deploy properly,

causing potentially deadly delays in the evacuation.

English: The fire took some time to get into the cabin.

That's a good thing.

But had a fuel tank been punctured

or some obstacle been in the way

and we had a much more rapid fire,

things could have been very different.

Narrator: They'll have to search for answers

without the help of the plane's flight data recorder.

The recorder is located in the tail section

and stopped recording when the tail smashed into the seawall.

There's no information on what was happening

at the moment the slides deployed.

Fedok: Okay.

Let's see what these slides can take.

Narrator: To get the data they need,

Jason Fedok turns to a crash test facility

more often used for testing cars.

Fedok: This was unlike anything anyone had ever seen before,

so we wanted to figure out how that happened.

Narrator: He discovers that at low speeds

the slides perform well.

But in high-speed impacts, like the one on board flight 214,

the inflation mechanism can fail quite easily.

Fedok: We made a recommendation to the FAA to look at the data

we produced from this accident

and see if there were improvements that could be made

to future slide design to help make that part more robust.

Narrator: The violent force of the impact

also accounts for the injuries suffered by the six people

thrown from the plane,

including the young teenager who was run over by a fire truck.

Autopsy results confirm she died immediately

after the crash impact.

She was already dead by the time her body was run over.

Fedok: One of the most important lessons here

is to always keep your seat belt fastened

whenever possible on an aircraft.

You never know when you're gonna have unexpected turbulence

or be in an accident.

Narrator: Investigators hope flight 214's flight recorders

will help them answer the other urgent question.

Jung Min: I've got control.

Narrator: Why did flight 214 slam into the seawall

in the first place?

Levy: I don't think we're going to make the runway.

Narrator: Modern flight recorders capture

detailed information about virtually every system on board,

including the complex automation

that helps the pilots fly the plane.

English: We were able to see all the basic things, like airspeed,

altitude, the configuration of the airplane.

We were also able to see all the inputs that the crew made.

Narrator: English carefully plots the data.

Most of it looks completely normal.

But then he spots something unexpected.

A little more than a minute away from the runway,

engine power suddenly drops to idle.

English: Right here.

Narrator: The sudden change in power settings makes no sense.

Normally, the last moments of flight

are when pilots need more power, not less.

They need extra thrust to overcome increased drag

from the landing gear and wing flaps.

The investigation has already determined

that there was nothing wrong with the engines themselves.

English: We could see that the engines were making proper power

all the way through the approach.

Narrator: The question now-- what was the crew doing

to control engine power

in the critical final moments of flight?

Jung Min: Speed.

English: So that brought us right back

to how did the pilots operate the airplane?

Why did they do what they did that got the airplane too low?

Cox: What really struck me

was how could a couple

of highly trained, experienced pilots

simply fly an airplane into the ground short of the runway?

I, that was the mystery.

Jung Min: Damn it!

Narrator: The investigation into Asiana 214 now focuses

squarely on the actions of the pilots.

Kang Kuk: Gear down, sir.

Narrator: Understanding every nuance

of the cockpit voice recording becomes crucial.

Bramble: The CVR is key.

Jung Min: Gear down.

Bramble: You can tell what the flight crew are doing.

You can tell what they're thinking sometimes

because they're verbalizing it.

You can tell how they're deciding,

you know, what to do next.

Narrator: They listen as the pilots prepare for landing.

Kang Kuk: Missed approach 3,000 feet.

Narrator: They combine what they hear with the FDR data

that shows how the pilots were manipulating the controls.

Jung Min: This seems a little high.

Narrator: As the crew nears the runway,

the recording hints at the first sign of trouble.

Kang Kuk: I will descend more.

Narrator: The plane isn't descending fast enough.

The captain flying takes steps to fix the problem,

but he doesn't explain his actions to his co-pilot.

Bramble: No call-out.

How's anyone supposed to know what he's doing?

Narrator: For investigator bill bramble,

it's a troubling clue.

Bramble: The pilot flying is supposed to actually

select things with the auto flight system

and call out what he's doing,

and the pilot monitoring is supposed to verify

that the change has actually occurred.

In this case, we saw kind of a breakdown

in that standard pattern of communication and coordination.

Kang Kuk: Flaps 20.

Narrator: What the recording reveals next is stunning.

Less than 90 seconds before impact,

the captain makes an inexplicable blunder.

He switches the autopilot to an incorrect setting,

flight level change mode.

That interrupts the landing and instructs the computer to climb

to the go-around altitude of 3,000 feet.

English: He made an entry to the autopilot

that at first actually made the airplane climb.

Obviously he didn't want to do that.

Bramble: The autopilot mode switches here,

starts all the confusion.

Narrator: To bring his plane back down,

the captain immediately pulls the throttles back to idle,

a move with major repercussions.

But once again, he doesn't tell the other pilot what he's doing.

Bramble: Not calling out one single action

wouldn't necessarily be a fatal flaw,

but in this particular case

it had a big influence on the conduct of the flight.

Jung Min: It's low.

Narrator: Investigators now understand

how the engines got to idle.

Kang Kuk: Yeah.

Narrator: But why would an experienced captain

make the mistake of leaving them there?

Computer: Pull up.

Jung Min: Oh, god.

Go around!

Narrator: And why did the crew not notice

they were dangerously low until it was too late?

Jung Min: Damn it!

Bramble: It's like they just sat there and watched it happen.

Narrator: To find answers, bramble and cox prepare

for a sensitive and difficult interview

with the pilot who was flying the plane.

Kang Kuk: I'll try to help if I can.

Bramble: We wanted to find out,

you know, how much of what happened did they understand?

We wanted to find out when they became aware

that something was amiss,

and so the only way to do that was by asking them.

Kang Kuk: I was a bit nervous.

Narrator: The captain explains he was worried

about landing in San Francisco,

on a day when there was no electronic runway equipment

to help guide him.

Cox: I thought that was very unusual

coming from an experienced pilot,

because no one really needs an electronic glide slope

on a clear day to be able to land an airplane.

It's a fundamental skill that you have to learn

from the time you're a private pilot.

Kang Kuk: Other pilots were making that landing.

I thought I should be able to make it, too.

Cox: He said everyone else was doing it,

so I could not say I could not do it.

Jung Min: It seems a little high.

Kang Kuk: I will descend more.

Bramble: I think he didn't want to show

that he was not confident or that he was not prepared.

But I think...

I think he just didn't want to admit the weakness.

Jung Min: It's low.

Narrator: The captain tells investigators

he doesn't understand

why the plane didn't have enough power on landing.

Kang Kuk: I know I made some mistakes,

but I was certain that the auto throttle

would control the speed.

Narrator: Like other modern jets,

the triple seven can automatically increase

or decrease engine power

through a system known as the auto throttle.

English: Similar to, but much more sophisticated,

than your cruise control.

Bramble: He was confident the auto throttle

was actually gonna take care of speed for him.

And in his prior experience, they had.

Narrator: During his triple seven flight training,

the captain was taught about

the auto throttle's special wake-up feature.

If the plane's speed drops too low,

the auto throttle engages and adds power,

even if it's switched off.

Kang Kuk: Amazing.

Bramble: As he had seen this demonstration in the simulator

that the auto throttles would wake up

even if the auto throttle was off,

so he had this really high level of expectancy

that the auto throttles would wake up,

advance the thrust, and keep them safe.

Narrator: Investigators consider a chilling possibility.

Did a critical automated system on a Boeing triple seven

fail in flight?

Is that what doomed Asiana 214?

Cox: So the auto throttle and autopilot

both change modes here and then again here.

Narrator: Investigators dig deeper into the flight data

from Asiana 214.

They search for any evidence of a failure or malfunction

in the plane's automated flight systems.

Cox: I think the most important thing that we wanted to know

was what auto throttle and autopilot modes were engaged

during the last two or three minutes of the flight.

Kang Kuk: Missed approach 3,000 feet.

Narrator: An undetected problem with the autopilot

or auto throttle

could easily have led the pilots to disaster.

Tracing all the computerized functions is a mammoth task.

English studies every input, every mode change.

The exhaustive analysis leaves no doubt.

None of flight 214's automated systems failed in any way.

But there is evidence of something else

that could finally explain what went wrong.

English: It was pretty evident that we could see

some strange things happening with automation inputs

while that airplane was on short final.

Narrator: The analysis reveals that the pilots of Asiana 214

punched in a bizarre sequence of inputs,

a sequence that most pilots would never carry out.

First choosing an autopilot mode rarely used during descent,

then pulling back on the thrust levers

when that error put the plane into a climb.

Cox: Bingo!

That does it.

Narrator: The unusual combination of commands

switches off the triple seven's built-in speed protection,

leaving the engines at idle.

English: At that point he disconnected the autopilot,

so now up, down, left, and right was in his hands.

He grabbed the throttles and reduced them,

like taking his foot off the gas.

By doing that, that sent the signal

to the auto throttle system

that he wanted control of the power as well.

So at that point in effect

the airplane was basically just gliding.

Narrator: Investigators finally understand why the auto throttle

did not re-engage and boost engine thrust on landing.

But puzzling questions remain.

Why was the captain so uncertain about autopilot functions?

And why couldn't the crew react in time to save the plane?

Cox: 22,000 hours between them.

You'd think they'd notice the speed.

Narrator: Translated from the original Korean,

the cockpit documents go a long way

toward providing some answers.

Cox: It turned out one of the important things

that we recovered was the pilot's training record,

which had detailed history of what he had accomplished

right up to the time of the accident.

Narrator: The documents reveal flight 214

was a critical training flight for captain lee Kang Kuk.

Kang Kuk: Is that the golden gate?

Narrator: He was transferring to the Boeing triple seven

after flying the airbus A320,

an aircraft with a very different type of automation.

Jung Min: Golden gate's over there.

That bridge goes to Oakland.

Abend: It's a different philosophy of flying,

and he had flown the airbus for quite some time,

so the transition may still have been an awkward moment.

Cox: It was a training flight.

Narrator: The training records reveal the captain

had been having trouble making the change.

Cox: The instructor was fairly critical.

He indicated he felt that the captain who was in training

wasn't sufficiently diligent and attentive to procedure.

Narrator: That recent criticism may have been

on lee Kang Kuk's mind as he headed to San Francisco.

Bramble: He was a little bit stressed,

because it was a training flight,

and he was being monitored by this more senior pilot,

and possibly because of this previous flight

where he hadn't performed so well.

Narrator: But why were the pilots so slow

to recognize the danger?

English: The question that was on everybody's mind

and carried all the way through this investigation

is what was going on in the pilots' heads?

Kang Kuk: Clear to land.

Narrator: Even though the landing system

was out of service, there was another way

for the pilots to know their plane was too low.

The runway is equipped with special lights

that change color to alert pilots

if the approach angle is off.

English: The papi, precision approach path indicator,

that also aid pilots in the proper vertical path,

those were operating and were operating properly

at the time of the accident.

Jung Min: It's low.

Narrator: The pilots were shown four red lights,

meaning the plane is dangerously low.

English: We had a lot of data,

and it pretty much showed us an airplane

that was working exactly as it was designed.

That wasn't difficult.

Getting into the whys of why human beings do what they do

or don't notice things is a lot more difficult,

and explaining that can be the hardest task of all.

Narrator: Especially troubling,

why did the more experienced commander wait

until it was too late before taking control of the plane?

Jung Min: I've got control.

Narrator: If he had intervened sooner,

he would almost certainly have prevented the accident.

English: The airplane was perfectly flyable

up until really the last minute,

so at any point there were a number of places

where someone could intervene, someone could take over,

someone could make a small change,

and this would have come out very differently.

Cox: Yeah, we're just trying to get a sense

of how much experience your guys would have flying by hand.

Can you get me some numbers on that?

Narrator: They learn that Asiana has strict policies

encouraging pilots to rely on their aircraft automation

as much as possible.

They rarely practice landing the plane by hand.

Cox: And we have to go to the company's procedures

and training, and there is where

I think we put our finger on the issue.

Controller: Cleared visual approach.

Narrator: Investigators are shocked to learn

that this arrival in San Francisco

was the first time the captain ever attempted

to land a triple seven

with no help from the glide slope signal on the runway.

Cox: When it comes to visual landings,

this guy's an absolute beginner.

Bramble: The vast majority of the time

he had been flying instrument approaches into airports,

even when he was technically flying the visual approach.

Cox: 10,000 hours, almost no hand flying.

Narrator: It's a stunning discovery.

Despite nearly 10,000 hours as an airline pilot,

the captain has almost no experience

flying his plane by hand.

Jung Min: It seems a little high.

Cox: You take away all the time that was on the autopilot,

and if you look at all of the flight hours that they had...

Kang Kuk: I will descend more.

Cox: ...they may have actually only had

a couple of hundred hours of hand flying the airplane,

maybe even less, during the years that they had been flying.

So they hadn't been honing their skills.

Narrator: Investigators also learn that the commander,

though an experienced pilot,

had never before supervised a training flight like this one.

Jung Min: It's low.

Narrator: His inexperience most likely led him to wait too long

before taking over the controls.

Jung Min: Speed!

English: As a flight instructor, knowing that critical point,

when to intervene,

when a pilot is, or a student is going a little bit too far,

is one of the hardest tasks to learn as an instructor.

It takes experience, time and a little bit of extra knowledge

being ahead of the airplane yourself as the instructor

to see these things starting to decay.

Narrator: Investigators agree the Asiana crew

made serious mistakes that caused the crash.

Cox: Bottom line, they let their speed drop.

Narrator: But they don't agree

on why the pilots made those mistakes.

Bramble: I think those modes would confuse most pilots.

Cox: But it's their job not to be confused.

Narrator: Bill bramble believes technology is to blame.

Bramble: The way that we design airplanes

and the way that airplane flight decks are evolving

are influencing the ability of flight crews to stay in the loop

and understand what's going on.

Narrator: But Roger Cox believes the fault lies

squarely with the human pilots.

Cox: We say pilots use cues to figure out, "where are we?".

So I couldn't quite grasp why a professional crew

hadn't picked up on these obvious cues

that were right in front of them.

Narrator: The crash of Asiana 214

sparks a heated discussion among industry experts

working to make aviation safer.

It's an age-old debate of man versus machine.

English: What's more significant?

Is it more significant that the pilots

did not simply take manual control

and fly this airplane to the runway or go around?

Or is it more significant that they were in this environment

of automation that some people think was too complex?

Bramble: Well, they fluked into it, the worst mode possible.

Narrator: The more complex automation becomes,

the more difficult it can be

for pilots to understand the entire system.

Bramble: I am not confident that the majority of pilots,

triple seven pilots at the time, would have been able to predict

the modes that the airplane would end up in.

Narrator: There have been other deadly accidents in recent years

that underscore bill bramble's concern

about automation confusion.

Turkish airways flight 1951 was carrying 128 passengers

on approach to Amsterdam

when a faulty altimeter sent incorrect data to the autopilot.

Speed began to drop.

Like the crew of Asiana 214,

the Turkish airways pilots failed to react,

thinking the plane's automation would maintain a safe speed.

Accidents like this are extremely rare.

Jung Min: It's low.

Narrator: But researchers say that's part of the problem.

Automation fails so rarely...

Kang Kuk: Yeah.

Narrator: ...that when it does,

pilots aren't able to react as quickly as they should.

Jung Min: Damn it!

Hang on! Hang on!

Bramble: To me, this accident shows

the inevitable consequences

of the evolution of the modern flight deck--

the increased automation, which has improved reliability,

efficiency and safety in many ways,

but has left us with some unintended consequences

when something anomalous occurs.

Narrator: But not everyone agrees that cockpit automation

has gone too far.

Cox: Bottom line, it's the pilot's responsibility

to fly that plane.

Having flown a lot of airliners

for well over 30 years in my career,

I always felt it was incumbent on me and other, all pilots

to fully and totally understand every aspect of the airplane,

particularly the flight path control,

the autopilot and the auto flight system,

so you understood what it was going to do.

Narrator: In their final report on the crash of Asiana 214,

investigators address both sides of the argument.

They list pilot error as the probable cause,

but they also cite the complexities

of the automation system as a contributing factor.

In an unusual move,

the report includes statements from four members

of the national transportation safety board,

each emphasizing their own personal views on the crash.

The report calls for better training for pilots,

including more time spent flying without the use of automation.

English: There's a great movement now in the industry

towards going back to basics.

We've talked a lot about over-reliance on automation,

but airplanes still fly pretty much the same way

they have for decades.

And we want to get back to making sure

that pilots are ahead of the airplane,

aware of what's going on around them,

and able to keep themselves in that loop of flying,

whether the automation is doing it or not.

Narrator: The report also urges more intuitive designs

for aircraft automation and better alarms in the cockpit

to warn pilots if their speed gets too low.

English: It's hardly ever that we have an accident

that's really just one thing.

The hard part is to say which one

is really that critical event?

Which is the straw that broke the camel's back?

If there is any such thing.

Sometimes it takes all those little things

to make the accident happen.