During the Asiana 214 response, an incident commander placed an officer who had not received aircraft firefighting training in charge, the NTSB said. No injuries could be attributed to the officer, it noted.

The airport fire department also had two vehicles equipped with turrets that could pierce a plane's fuselage. But while the Federal Aviation Administration had given guidance on how to pierce a fuselage, it had not given guidance on when to pierce a plane, the NTSB said.

And two emergency medical buses failed to arrive at the scene, the NTSB said. The buses were not physically deployed during monthly drills, the board said, likely playing a role in the failure to use them during the crash.

"It's those types of things you need to exercise, so that when it's game time, you understand the realities of what you have to do," Price said. "I think it's up to the FAA to raise the standards for airports," he said.

The safety board said the airport initially deployed seven vehicles to the crash, exceeding the FAA-required minimum of three vehicles. And some 23 rescuers were initially deployed, though the FAA has no minimum staffing level. That means victims of crashes at smaller airports "may not be afforded the same level of protection that the passengers of flight 214 had," the board said.

What went right

Experts say the crash could have been much worse; passengers benefited from safety improvements.

"I've watched that (crash) video time and again," Price said. "The structural integrity of that plane remained amazingly intact for what it went through. It was extraordinary. It protected the occupants very well."

"If there's anything good to be had from all the accidents in the past and all the lives lost, it's made for amazing changes in the design of an aircraft," Price said.

The main landing gear sheared away from the wings, by design. Passenger seats withstood the brutal g-forces. Luggage bins did not fall on the passengers or block their evacuation. The jet fuel did not erupt on impact.

And when a fire finally broke out -- the result of leaking oil from the plane's right engine, which came to rest next to the fuselage -- it did not spread quickly. Fifteen minutes passed before black smoke was seen pouring from the plane's left door.

Authorities note that 99 percent of the plane's occupants survived -- a rate that would have seemed impossible only a decade or two ago.

Indeed, two of the three deaths may have been avoidable, the NTSB said. Two girls ejected from the plane had not buckled their seatbelts, investigators said, and likely would have survived if they had. A fire truck rolled over one of the ejected girls in the chaos of the crash scene.

The third girl had on a seatbelt, but died at the hospital six days later of injuries suffered in the crash.