The National Transportation Safety Board today concluded that the crash of Asiana flight 214 at San Francisco International Airport last year was caused by pilot error, or what the NTSB called “the flight crew's mismanagement of the approach and inadequate monitoring of airspeed.”

The accident ultimately killed three teen girls who had planned to come to West Valley Christian School in Canoga Park for a summer program.

See also: Were Asiana Pilots Drinking? We Might Never Know

Interestingly, the report officially rules out alcohol as a possible factor, even though at least two of the pilots in the cockpit acknowledge in NTSB documents that they were not tested for booze in the days after the crash:
The Board concluded that “the use of alcohol or drugs … were not factors in the accident.”

An NTSB spokesman told us that its determination came from toxicology tests:

The NTSB was eventually provided with documentation and other information from the toxicology tests that were taken that offered no evidence that alcohol and drugs were factor.

However, the Board's own reports say that the hair follicle tests used on the pilots “look for evidence of 47 different substances, including amphetamine-type stimulants, cannabinoids, opioids, cocaine, and benzodiazepines.” There's no mention of alcohol in association with those tests.

The NTSB told us previously that it could not test the pilots for alcohol because Asiana is not an American-based carrier subject to federal scrutiny in this realm. Never mind that the crash happened at an American airport.

Both Capt. Lee Kang Kuk and Relief Capt. Lee Jong Joo told NTSB investigators in interviews conducted three and four days after the July 6 crash that they had not been tested for alcohol.

See also: Chinese Girls Killed in SFO Crash Were Best Friends and Top of Class

Kuk was a “trainee captain” and the main pilot behind the controls during the accident, feds say. According to the NTSB's summary of Kuk's interviews:

Asked whether anyone asked him to undergo a drug or alcohol test after the accident, he said no, nobody asked him.

The NTSB reports that he told investigators that he had 250 milliliters – an amount equivalent to a can of Red Bull – of beer on July 5.

Joo said “he was never asked to take a drug or alcohol test after the accident and did not provide any samples,” according to the NTSB's summary of his post-crash interview.

Bong Dong Won, first officer, told investigators ” … his last use of alcohol was a glass of wine the evening of July 4,” according to the NTSB.

Capt. Lee Jung Min “did not recall taking any alcohol because he rarely drank,” the Board states.

The NTSB summarized the events leading up to the fatal crash this way: 

 … The flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath as it neared the runway. In response to the excessive altitude, the captain selected an inappropriate autopilot mode and took other actions that, unbeknownst to him, resulted in the autothrottle no longer controlling airspeed.

As the airplane descended below the desired glidepath, the crew did not notice the decreasing airspeed nor did they respond to the unstable approach. The flight crew began a go-around maneuver when the airplane was below 100 feet, but it was too late and the airplane struck the seawall.

NTSB acting chairman Christopher A. Hart said “the flight crew over-relied on automated systems without fully understanding how they interacted” and emphasized that even with planes that can practically fly themselves “the human must be the boss.”

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