NTSB: Firefighters, Officers Lacked Training to Handle Asiana Crash

June 25, 2014
Investigators said crews missed a 'short window of opportunity' to prevent the girl from being runover.

June 24--Firefighters missed a "short window of opportunity" to prevent a 16-year-old survivor of the Asiana Airlines crash from being run over by two San Francisco fire rigs, a death that "never should have" happened, National Transportation Safety Board officials said Tuesday.

At least two firefighters who looked at Ye Meng Yuan and decided she was dead could have examined her to verify that conclusion, but failed to do so, safety board investigator Jason Fedok said at a Washington hearing looking into the July 6 crash.

Ye, a Chinese schoolgirl flying to the U.S. to attend a religious camp in the San Fernando Valley, and a companion who also died were thrown from the plane when it crashed because they weren't wearing seat belts, Fedok said. They would probably have survived if they had been belted in, he said.

The third Chinese girl killed in the crash had her seat belt on but was struck in the head by a door on the Boeing 777 that was knocked loose on impact, Fedok said.

'Seconds counted'

Christopher Hart, the safety board's acting chairman, said firefighters and other first responders had "charged into the wreckage" to find survivors, despite not knowing when a fire that broke out on the plane might suddenly intensify.

"Seconds counted," Hart said. "Nonetheless, something happened that never should have."

Two fire rigs rolled over Ye as she lay on the ground near the burning plane's left wing. A San Mateo County coroner's autopsy found she was alive when the rigs struck her.

Safety board investigators concluded that firefighters "did not appropriately triage" Ye after looking at her and deciding she was dead.

Video footage

Video footage shows "a short window of opportunity for at least two firefighters to perform triage on (the girl) and verify their visual assessments," Fedok said, "but they did not do so."

The safety board did not identify the firefighters. But two, Lt. Christine Emmons and Roger Phillips, have said they saw Ye on the ground and assumed she was dead without examining her.

Such an assessment, experts say, involves physical contact, including checking for breathing and pulse.

Touching is essential

"You can't assess without touching," said Peter Green, a former San Francisco fire paramedic who developed the airport's multi-casualty triage response plan in 1999.

The first foam-spraying fire rig rolled over Ye 23 minutes after the crash, and the second one hit her 11 minutes later, investigators found.

Justin Green, an attorney for Ye's family, said the Fire Department and the city have never apologized for what happened. City officials have yet to respond to the family's legal claim, which is the first step toward a lawsuit, he said.

Basic step 'overlooked'

"Ultimately, you have a very basic step that was overlooked by more than one firefighter," Green said. "Here they look at someone, but no one checks her pulse."

He added, "To the family, this is more about admitting a mistake was made and making sure that it doesn't happen again. I don't think the family has heard what they need to hear."

At a safety board hearing in December, Assistant Deputy Fire Chief Dale Carnes said that what happened to Ye was "not a matter of us being careless or callous -- it was the fact that we were dealing with a complex and dynamic environment and we were focused on saving as many lives as possible."

On Tuesday, the Fire Department issued a statement from Chief Joanne Hayes-White in which she praised the investigation as "thorough and comprehensive."

She said the department has beefed up training forfirefighters and commanders and improved triage tracking and communications.

Commander training

The federal safety board said it had concerns about fire commanders' lack of training for handling crash scenes and communications problems among the first responders, though investigators said those were not factors in Ye's death.

Fedok noted that commanders "had no previous experience working at an airport, nor had they ever been involved in an airport disaster exercise."

Fedok added that there were "numerous problems with communication" among the first responders, including an incorrect report to the incident commander that there was no fire on the plane. Several emergency personnel said communication difficulties, including the lack of a common radio frequency, had hindered the response, Fedok said.

Airport Director John Martin said in a statement that SFO has taken steps to improve radio communications and is about to buy an emergency alert system. It has also procured a Boeing 767 for "realistic emergency training drills," he said.

Jaxon Van Derbeken is a San Francisco Chronicle staff writer. E-mail: [email protected]

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