All language subtitles for Air.Disasters.S09E02.Terror.in.San.Francisco.1080p.PMTP.WEB-DL.AAC2.0.H.264-maldini_track3_[eng]

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.