MIAMI — Fresh details came out Wednesday during a public investigative hearing in Washington, DC on the crash of Asiana 214. The hearing, run by the National Transportation Safety Board (NTSB), discovered that the crew ignored or failed to act on multiple signs that something was amiss.

The investigation on Wednesday focused primarily on failure to act on the flightdeck, and confusion on how to properly operate the automated thrust system. Three pilots—one flying the aircraft, an instructor pilot in the right seat, and a relief co-pilot in the jumpseat—were in the cockpit at the time of the incident. The relief co-pilot, Bong Dong Won, testified that he realized the airplane was descending too quickly as it passed 4,000 feet, but did not say anything. As the airplane passed 1,000 feet, Won alerted the commanding pilot four times that their sink rate was too high.

Captain Lee Kang Kuk, a new 777 pilot who was in command at the time of the crash, failed to respond to the warnings. Contributing to the crash, the auto-throttle was disengaged inadvertently and set to idle. With the crew believing the airplane was taking care of the speed for them, no one appears to have noticed the airplane was flying up to 40mph slower than it should have been. Kuk did realize he was too low, based on sighting visual indicators (PAPI) on the ground, and nosed up to correct the problem. Since the airplane was going too slow, it only made it worse.

The instructor pilot, Lee Jung Min, finally commanded a go-around at approximately 200 feet, but by then it was already too late. The airplane slammed into a seawall, severing the tail, before careening down the runway on a perfectly sunny day in San Francisco International Airport (SFO). Three died, and 180 were injured in the crash. (New video at bottom).

Kuk testified, though via video as none of the pilots were at the hearing in person, that he had been concerned about flying a visual approach into SFO. Normally the airport provides what is known as an instrument landing system, or ILS, which streams real-time, exceptionally precise guidance to the cockpit on the aircraft’s approach to the runway. On the day of the crash, however, the system was inoperative, leaving the crew to perform a visual approach with the aid of a less precise lighting system.

While the primary contributing factors are outlined above, experts have agreed it is concerning that a highly trained crew could manage to crash a perfectly good airplane on clear, sunny day. Cultural critiques have played heavily into analysis by both the NTSB and elsewhere. Asian carriers have often received significant critiques for over-reliance on automations/checklists and for cockpit communication.

Many Asian cultures—including that of Korea, where Asiana is based—place a high priority on respecting seniority and authority. The latter came into play repeatedly during the incident, with Won realizing the problem but failing to notify the more senior pilots for some time. Additionally, Captain Kuk told investigators that he was very hesitant to call for a go-around with the more senior instructor pilot, Jung Min.

Asiana has worked hard to buck that trend, revamping their entire training procedure in the past few years to work to open up the cockpit environment. But it is hard to change mindsets overnight. Kuk acknowledged to investigators that the go-around should have been done, but told them “the instructor pilot got the authority. Even I am on the left seat; that is very hard to explain, that is our culture.”

Multiple experts and several op-eds have come out after the crash criticizing Asian cultures for an overly heavy reliance on automation. Most point to the inability of the crew to land the airplane on a perfectly clear day on what should have been a textbook landing.