Asiana Airlines Flight 214
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Asiana Airlines Flight 214 was a scheduled transpacific passenger flight from Incheon International Airport near Seoul, South Korea, to San Francisco International Airport (SFO) in the United States. On the morning of Saturday, July 6, 2013, the Boeing 777-200ER aircraft operating the flight crashed on final approach into SFO. Of the 307 people aboard, two passengers died at the crash scene, and a third died in a hospital several days later, all three of them teenage Chinese girls. Another 187 individuals were injured, 49 of them seriously. Among the injured were three flight attendants who were thrown onto the runway while still strapped in their seats when the tail section broke off after striking the seawall short of the runway. It was the first crash of a Boeing 777 that resulted in fatalities since that aircraft model entered into service in 1995.
Crash
On July 6, 2013, Flight OZ214 took off from Incheon International Airport (ICN) at 5:04 p.m. KST (08:04 UTC), 34 minutes after its scheduled departure time. It was scheduled to land at San Francisco International Airport (SFO) at 11:04 a.m. PDT (18:04 UTC).
The flight was cleared for a visual approach to runway 28L at 11:21 a.m. PDT, and told to maintain a speed of 180 knots (330 km/h; 210 mph) until the aircraft was 5 miles (8.0 km) from the runway. At 11:26 a.m., Northern California TRACON ("NorCal Approach") passed air traffic control to the San Francisco tower. A tower controller acknowledged the second call from the crew at 11:27 a.m. when the plane was 1.5 miles (2.4 km) away, and gave clearance to land.
The weather was very good; the latest METAR reported light wind, 10 miles (16 km) visibility (the maximum it can report), no precipitation, and no forecast or reports of wind shear. The pilots performed a visual approach[3] assisted by the runway's precision approach path indicator (PAPI).
At 11:28 a.m., HL7742 crashed short of runway 28L's threshold. The landing gear and then the tail struck the seawall that projects into San Francisco Bay. Both engines and the tail section separated from the aircraft. The NTSB noted that the main landing gear, the first part of the aircraft to hit the seawall, "separated cleanly from [the] aircraft as designed". The vertical and both horizontal stabilizers fell on the runway before the threshold.
The remainder of the fuselage and wings rotated counter-clockwise approximately 330 degrees, as it slid westward. Video showed it pivoting about the wing and the nose while sharply inclined to the ground. It came to rest to the left of the runway, 2,400 feet (730 m) from the initial point of impact at the seawall.
After a minute or so, a dark plume of smoke was observed rising from the wreckage. The fire was traced to a ruptured oil tank above the right engine. The leaking oil fell onto the hot engine and ignited. The fire was not fed by jet fuel. Two evacuation slides were deployed on the left side of the airliner and used for evacuation. Despite damage to the aircraft, "many ... were able to walk away on their own". The slides for the first and second doors on the right side of the aircraft (doors 1R and 2R) deployed inside the aircraft, pinning the flight attendants seated nearby.
According to NBC reports in September 2013, the US government had been concerned about the reliability of evacuation slides for decades: "Federal safety reports and government databases reveal that the NTSB has recommended multiple improvements to escape slides and that the Federal Aviation Administration has collected thousands of complaints about them." Two months before the accident at SFO, the FAA issued an airworthiness directive ordering inspection of the slide release mechanism on certain Boeing 777 aircraft, so as to detect and correct corrosion that might interfere with slide deployment. This was the third fatal crash in Asiana's 25-year history.
The weather was very good; the latest METAR reported light wind, 10 miles (16 km) visibility (the maximum it can report), no precipitation, and no forecast or reports of wind shear. The pilots performed a visual approach[3] assisted by the runway's precision approach path indicator (PAPI).
At 11:28 a.m., HL7742 crashed short of runway 28L's threshold. The landing gear and then the tail struck the seawall that projects into San Francisco Bay. Both engines and the tail section separated from the aircraft. The NTSB noted that the main landing gear, the first part of the aircraft to hit the seawall, "separated cleanly from [the] aircraft as designed". The vertical and both horizontal stabilizers fell on the runway before the threshold.
The remainder of the fuselage and wings rotated counter-clockwise approximately 330 degrees, as it slid westward. Video showed it pivoting about the wing and the nose while sharply inclined to the ground. It came to rest to the left of the runway, 2,400 feet (730 m) from the initial point of impact at the seawall.
After a minute or so, a dark plume of smoke was observed rising from the wreckage. The fire was traced to a ruptured oil tank above the right engine. The leaking oil fell onto the hot engine and ignited. The fire was not fed by jet fuel. Two evacuation slides were deployed on the left side of the airliner and used for evacuation. Despite damage to the aircraft, "many ... were able to walk away on their own". The slides for the first and second doors on the right side of the aircraft (doors 1R and 2R) deployed inside the aircraft, pinning the flight attendants seated nearby.
According to NBC reports in September 2013, the US government had been concerned about the reliability of evacuation slides for decades: "Federal safety reports and government databases reveal that the NTSB has recommended multiple improvements to escape slides and that the Federal Aviation Administration has collected thousands of complaints about them." Two months before the accident at SFO, the FAA issued an airworthiness directive ordering inspection of the slide release mechanism on certain Boeing 777 aircraft, so as to detect and correct corrosion that might interfere with slide deployment. This was the third fatal crash in Asiana's 25-year history.
Passengers
Two 16-year-old girls with Chinese passports were found dead outside the aircraft soon after the crash, having been thrown out of the aircraft during the accident. One was accidentally run over by an airport crash tender after being covered in fire-fighting foam. On July 19, 2013, the San Mateo County Coroner's office confirmed that the girl was still alive prior to being run over by a rescue vehicle, and was killed due to blunt force trauma. On January 28, 2014, the San Francisco city attorney's office announced their conclusion that the girl was already dead when she was run over.
Four flight attendants seated at the rear were ejected from the aircraft when the tail section broke off, and they survived.
Ten people in critical condition were admitted to San Francisco General Hospital and a few to Stanford Medical Center. Nine hospitals in the area admitted 182 injured people. San Francisco Fire Department Chief Joanne Hayes-White, after checking with two intake points at the airport, told reporters that all on board had been accounted for. A third passenger, a 15-year-old Chinese girl, died of her injuries at San Francisco General Hospital six days after the accident.
Of the passengers, 141 (almost half) were Chinese citizens. More than 90 of them had boarded Asiana Airlines Flight 362 from Shanghai Pudong International Airport, connecting to Flight 214 at Incheon. Incheon serves as a major connecting point between China and North America. In July 2013, Asiana Airlines operated between Incheon (Seoul) and 21 cities in mainland China. Seventy students and teachers traveling to the United States for summer camp were among the Chinese passengers. Thirty of the students and teachers were from Shanxi, and the others were from Zhejiang. Five of the teachers and 29 of the students were from Jiangshan High School in Zhejiang; they were traveling together. Thirty-five of the students were to attend a West Valley Christian School summer camp. The Shanxi students originated from Taiyuan, with 22 students and teachers from the Taiyuan Number Five Secondary School and 14 students and teachers from the Taiyuan Foreign Language School. The three passengers who died were in the Jiangshan High School group to West Valley camp.
Ten people in critical condition were admitted to San Francisco General Hospital and a few to Stanford Medical Center. Nine hospitals in the area admitted 182 injured people. San Francisco Fire Department Chief Joanne Hayes-White, after checking with two intake points at the airport, told reporters that all on board had been accounted for. A third passenger, a 15-year-old Chinese girl, died of her injuries at San Francisco General Hospital six days after the accident.
Of the passengers, 141 (almost half) were Chinese citizens. More than 90 of them had boarded Asiana Airlines Flight 362 from Shanghai Pudong International Airport, connecting to Flight 214 at Incheon. Incheon serves as a major connecting point between China and North America. In July 2013, Asiana Airlines operated between Incheon (Seoul) and 21 cities in mainland China. Seventy students and teachers traveling to the United States for summer camp were among the Chinese passengers. Thirty of the students and teachers were from Shanxi, and the others were from Zhejiang. Five of the teachers and 29 of the students were from Jiangshan High School in Zhejiang; they were traveling together. Thirty-five of the students were to attend a West Valley Christian School summer camp. The Shanxi students originated from Taiyuan, with 22 students and teachers from the Taiyuan Number Five Secondary School and 14 students and teachers from the Taiyuan Foreign Language School. The three passengers who died were in the Jiangshan High School group to West Valley camp.
Investigation
The National Transportation Safety Board (NTSB) sent a team of 20 to the scene to investigate. On July 7, 2013, NTSB investigators recovered the flight data recorder and cockpit voice recorder and transported them to Washington, D.C., for analysis. Additional parties to the investigation include the Federal Aviation Administration, Boeing, Pratt & Whitney, and the Korean Aviation and Railway Accident Investigation Board (ARAIB). ARAIB's technical adviser is Asiana Airlines.
ARAIB tested the pilots for drug use four weeks after the accident; the tests proved negative.
The NTSB's investigative team completed the examination of the airplane wreckage and runway. The wreckage was removed to its secure storage location at San Francisco International Airport. The Airplane Systems, Structures, Powerplants, Airplane Performance, and Air Traffic Control investigative groups completed their on-scene work. The Flight Data Recorder and Cockpit Voice Recorder groups completed their work in Washington. The Survival Factors/Airport group completed their interviews of the first responders. The next phase of the investigation included additional interviews, examination of the evacuation slides and other airplane components, and a more detailed analysis of the airplane's performance. The final report was released in June 2014. On July 19, San Mateo County coroner confirmed that one passenger died of injuries received from a responding fire truck, not from the crash itself.[45] The District Attorney ruled that her death was accidental and that the driver of the fire truck involved would not face any criminal proceedings.
The final report into the crash was released on June 24, 2014. The NTSB found that the "Mismanagement of Approach and Inadequate Monitoring of Airspeed Led to Crash of Asiana flight 214". The NTSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath. In response, the captain selected an inappropriate autopilot mode, which, without the captain's awareness, resulted in the autothrottle no longer controlling airspeed. The aircraft then descended below the desired glide path with the crew unaware of the decreasing airspeed. The attempted go-around was conducted below 100 feet, by which time it was too late. Over-reliance on automation and lack of systems understanding by the pilots were cited as major factors contributing to the accident.
The NTSB further determined that the pilot's faulty mental model of the airplane's automation logic led to his inadvertent deactivation of automatic airspeed control. In addition, Asiana's automation policy emphasized the full use of all automation and did not encourage manual flight during line operations. The flight crew's mismanagement of the airplane's vertical profile during the initial approach led to a period of increased workload that reduced the pilot monitoring's awareness of the pilot flying's actions around the time of the unintended deactivation of automatic airspeed control. Insufficient flight crew monitoring of airspeed indications during the approach likely resulted from expectancy, increased workload, fatigue, and automation reliance. Lack of compliance with standard operating procedures and crew resource management were cited as additional factors. The NTSB reached the following final conclusion:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; the pilot flying's inadequate training on the planning and executing of visual approaches; the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and flight crew fatigue, which likely degraded their performance.
The NTSB's investigative team completed the examination of the airplane wreckage and runway. The wreckage was removed to its secure storage location at San Francisco International Airport. The Airplane Systems, Structures, Powerplants, Airplane Performance, and Air Traffic Control investigative groups completed their on-scene work. The Flight Data Recorder and Cockpit Voice Recorder groups completed their work in Washington. The Survival Factors/Airport group completed their interviews of the first responders. The next phase of the investigation included additional interviews, examination of the evacuation slides and other airplane components, and a more detailed analysis of the airplane's performance. The final report was released in June 2014. On July 19, San Mateo County coroner confirmed that one passenger died of injuries received from a responding fire truck, not from the crash itself.[45] The District Attorney ruled that her death was accidental and that the driver of the fire truck involved would not face any criminal proceedings.
The final report into the crash was released on June 24, 2014. The NTSB found that the "Mismanagement of Approach and Inadequate Monitoring of Airspeed Led to Crash of Asiana flight 214". The NTSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath. In response, the captain selected an inappropriate autopilot mode, which, without the captain's awareness, resulted in the autothrottle no longer controlling airspeed. The aircraft then descended below the desired glide path with the crew unaware of the decreasing airspeed. The attempted go-around was conducted below 100 feet, by which time it was too late. Over-reliance on automation and lack of systems understanding by the pilots were cited as major factors contributing to the accident.
The NTSB further determined that the pilot's faulty mental model of the airplane's automation logic led to his inadvertent deactivation of automatic airspeed control. In addition, Asiana's automation policy emphasized the full use of all automation and did not encourage manual flight during line operations. The flight crew's mismanagement of the airplane's vertical profile during the initial approach led to a period of increased workload that reduced the pilot monitoring's awareness of the pilot flying's actions around the time of the unintended deactivation of automatic airspeed control. Insufficient flight crew monitoring of airspeed indications during the approach likely resulted from expectancy, increased workload, fatigue, and automation reliance. Lack of compliance with standard operating procedures and crew resource management were cited as additional factors. The NTSB reached the following final conclusion:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; the pilot flying's inadequate training on the planning and executing of visual approaches; the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and flight crew fatigue, which likely degraded their performance.
| Incident summary | |
|---|---|
| Date | July 6, 2013 |
| Summary | Descent below visual glidepath and impact with seawall due to pilot error |
| Site | San Francisco International Airport |
| Passengers | 291 |
| Crew | 16 |
| Fatalities | 3 |
| Injuries (non-fatal) | 187 |
| Survivors | 304 |
| Aircraft type | Boeing777-28EER |
| Operator | Asiana Airlines |
| Registration | HL7742 |
| Flight origin | Incheon International Airport |
| Destination | San Francisco International Airport |
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