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Asiana Airlines Crash 214 - Coggle Diagram
Asiana Airlines Crash 214
Management
Training
Lack of training for the airplane pilots in manual landing
Lack of training with equipment (auto flight, manual flying, (Ntsb.gov. 2020)
monitoring equipment(Ntsb.gov. 2020)
Procedural event Analysis Tool
Understanding/Comprehension
incorrect action performance(Ntsb.gov. 2020)
Understanding Auto flight system(Ntsb.gov. 2020)
Understanding flight directors(Ntsb.gov. 2020)
Human Factors Investigation Tool
Workload
Failure to Land plane(Ntsb.gov. 2020)
Hierarchical Task Analysis Tool
Workplace
Equipment Design
four red lights displayed to indicating continuing descent below glide path (Ntsb.gov. 2020)
authothrottle changed to the HOLD mode in which does not control airspeed (Ntsb.gov. 2020)
Systematic Cause Analysis Technique
Environment
Weather
Visual conditions(Ntsb.gov. 2020)
7 knots wind (low wind) (Ntsb.gov. 2020)
Minimal cloud(Ntsb.gov. 2020)
No precipitation (Ntsb.gov. 2020)
Incident Cause and Analysis Method
People
Flight Crew
inadequate monitoring of airspeed(Ntsb.gov. 2020)
delayed execution of a go-around(Ntsb.gov. 2020)
flight crews not following expected communication and coordination regarding the use of the auto-throttle and autopilot(Ntsb.gov. 2020)
fatigue(Ntsb.gov. 2020)
Circadian Rythems or jetlag(Ntsb.gov. 2020)
Delayed reaction(Ntsb.gov. 2020)
Procedural Event Analysis Tool
Emergency Responders
Arriving incident commander placed in charged did not receive Aircraft rescue and firefight training (ARFF)(Ntsb.gov. 2020)
Cognitive Reliability and Error Analysis Method
Pilots
unintended deactivation of automatic airspeed control(Ntsb.gov. 2020)
training speculation
Asiana's automation policy did not encourage manual flight during line operations(Ntsb.gov. 2020)
Pilot had lack of experience flying the 777 manually during experience(Ntsb.gov. 2020)
where expected to complete a go around (Ntsb.gov. 2020)
Cognitive Reliability and Error Analysis Method